186 results
94y · Male·aspiration pneumonia due to stroke following surgery to repair fracture of neck …
A 94-year-old man with dementia died from aspiration pneumonia following a stroke after hip surgery. The stroke and hip fracture resulted from being pushed by another resident with Alzheimer's dementia at an aged care fa…
77y · Female·Airways obstruction by tissue paper
A 77-year-old woman with depression, anxiety, and chronic pain died from airway obstruction by tissue paper at an aged care facility. She had expressed suicidal ideation, attempted self-harm, and was found with tissues i…
54y · Female·Pulmonary thromboembolism complicating left calf deep venous thrombosis in the s…
54-year-old woman with frontotemporal dementia and Parkinson's disease died from pulmonary thromboembolism complicating deep venous thrombosis. She fell during the night at a disability accommodation facility and was fou…
89y · Male·combination of biochemical consequences of colonic pseudo-obstruction and faecal…
An 89-year-old man with multiple comorbidities including previous colon cancer died from faecal impaction and stercoral colitis. He resided in a residential aged care facility (RACF) where staff failed to recognize that …
93y · Female·acute right lower limb ischaemia
Adelina Zito, a 93-year-old resident of an aged care facility, died from acute limb ischaemia after a 6-7 day delay in escalating her care. She developed right leg pain around 26-28 July 2022 that worsened despite parace…
78y · Female·Bronchopneumonia
CFT, a 78-year-old woman with chronic schizophrenia, intellectual disability, and dementia, died of bronchopneumonia with hypothermia and coronary atherosclerosis. She lived with her nephew RDS who was her carer. Multipl…
64y · Male·complications in association with thermal injuries in a man with underlying chro…
Kim Vulich, a 64-year-old man with decompensated liver cirrhosis from chronic alcohol use, developed hepatic encephalopathy and cognitive impairment including possible Korsakoff syndrome. Despite SAT guardianship orders …
89y · Male·Cervical spine trauma
Robert Driver, 89, died from cervical spine trauma sustained after being struck by another dementia-affected resident in an aged care facility. He was assessed overnight at the facility and transferred to hospital the fo…
Unknown·COVID-19 infection with various comorbidities as contributing factors
This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…
81y · Female·Multisystem failure in the setting of hyponatraemia secondary to chronic malnutr…
An 81-year-old woman with chronic schizophrenia, heart failure, and dementia died from multisystem failure secondary to severe malnutrition and hyponatraemia. Over four years, her son (Medical Power of Attorney) progress…
79y · Male·Respiratory failure due to haemothorax and hospital-acquired pneumonia due to mu…
A 79-year-old man with extensive comorbidities died following multiple falls in residential aged care. He was identified as high falls risk on admission but experienced inadequate falls prevention after a second fall on …
57y · Male·partially suspended hanging
A 57-year-old man with longstanding alcohol use disorder, anxiety, and recent-onset suicidal ideation died by hanging in hospital after a 108-day admission for orthopaedic injuries sustained from intentional jumping. He …
82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis
An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was …
98y · Female·Sepsis due to sacral pressure ulcer complicated by osteomyelitis against a backg…
A 98-year-old woman with dementia and multiple comorbidities died from sepsis secondary to a sacral pressure ulcer that progressed to osteomyelitis while in residential aged care. The coroner identified systemic clinical…
76y · Male·hospital-acquired pneumonia, age-related frailty, consequences of left neck of f…
Leslie Bruce Whish-Wilson, 76, sustained a fall in his aged care room in January 2024, leading to a right femoral neck fracture requiring surgical repair. Post-operatively, he developed hospital-acquired pneumonia compli…
92y · Male·periprosthetic fracture of the left hip sustained from a fall from standing posi…
A 92-year-old man with complex cardiac history was admitted to Royal Hobart Hospital with chest pain and atrial fibrillation. He remained in the Emergency Medical Unit (EMU) for five days despite clinical deterioration, …
76y · Female·multiple organ failure due to abdominal wall cellulitis (surgically treated)
Mrs Crowther, a 76-year-old obese woman with multiple comorbidities in residential aged care, died from multiple organ failure secondary to abdominal wall cellulitis. A critical care failure occurred when an old dressing…
85y · Male·Heat stroke
An 85-year-old man with dementia, diabetes, and aortic stenosis died from heat stroke after spending 2 hours 18 minutes unmonitored in an unsheltered outdoor garden area at a residential aged care facility. The resident …
87y · Male·Combined effects of sotalol toxicity on a background of severe valvular and athe…
An 87-year-old man with Alzheimer's disease died in a residential aged care facility after ingesting Sotalol, a cardiac medication not prescribed to him. The medication trolley was left unlocked and accessible despite fa…
81y · Male·Chronic lung disease (severe COPD) with atherosclerotic cardiovascular and valvu…
An 81-year-old man with severe COPD died following inappropriate interhospital transfer to a private hospital and subsequent management errors. Key clinical lessons: (1) patients with CO2 retention require explicit ident…
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