129 results
58y · Male·multiorgan failure due to sepsis resulting from repeatedly fractured left humeru…
Wayne Anthony Lowe, aged 58, died of multiorgan failure due to sepsis following repeated humeral fractures sustained in falls. He was admitted with a right proximal humeral fracture from an intoxicated fall, discharged a…
68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pul…
Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in…
0y · Unknown·unascertained
A 10-day-old neonate born at 36 weeks gestation presented to hospital with signs of sepsis including hypothermia, lethargy, poor feeding, and jaundice. Critical failures in recognition and triage occurred: the infant was…
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 …
61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed
A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…
47y · Male·Sudden cardiac death in association with COVID-19 infection
Alen Imbrisak, a 47-year-old man incarcerated at Junee Correctional Centre, died on 26 January 2022 from sudden cardiac death in association with COVID-19 infection. He tested positive on 25 January 2022 during a centre-…
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…
11y · Male·Sepsis
An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…
63y · Female·Sepsis with multiorgan failure in the setting of limb cellulitis complicating a …
A 63-year-old woman with multiple comorbidities (obesity, chronic lung disease, obstructive sleep apnoea, prior cerebrovascular disease with hemiparesis) sustained a 4cm laceration to her right shin from a motorised whee…
0y · Male·unascertained, in an unsafe sleeping environment, on a background of respiratory…
Baby Caleb, aged 2 months, died on 30 November 2018 in an unsafe sleeping environment while his mother co-slept with him on a fold-out sofa in a squalid home. He had a concurrent respiratory tract infection. The coroner …
54y · Male·multi-organ failure and sepsis complicating fulminant pneumonia with empyema (op…
A 54-year-old man died from sepsis and multi-organ failure secondary to fulminant pneumonia with empyema. He presented to his GP on 1 April 2021 with concerning signs including bilateral oedema, fever, and respiratory sy…
76y · Male·pulmonary thromboembolism in the setting of deep vein thrombosis
A 76-year-old man with a history of unprovoked DVT/PE on lifelong warfarin was admitted with COVID-19 and developed a bleeding duodenal ulcer requiring endoscopic treatment. Warfarin was ceased to prevent further bleedin…
26y · Female·meningococcal infection (Neisseria meningitidis W strain) causing septicaemia
Ashleigh Rebecca Hunter, a previously healthy 26-year-old, died from meningococcal septicaemia (W strain) within 3 hours of arriving at Royal Perth Hospital. She presented with severe generalised pain (10/10), tachycardi…
75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis
A 75-year-old woman with chronic pain and previous staphylococcal infections presented to Glen Innes District Hospital with a swollen, warm right knee 10 days after a corticosteroid injection. Junior doctor Dr M. appropr…
12y · Female·Hypoxic ischaemic encephalopathy complicating an aortic root abscess (operated) …
A 12-year-old Aboriginal girl with a bicuspid aortic valve and autism spectrum disorder presented with a week of fever and non-specific symptoms (cough, vomiting, abdominal pain, chest pain) to a rural hospital. Despite …
Female·Betty: cardiac arrhythmia complicating heart failure due to consequences of past…
This inquest examined three deaths of young Aboriginal women from Doomadgee (ages 18, 37, and 17) from rheumatic heart disease (RHD) complications between September 2019 and September 2020. All three deaths were preventa…
84y · Male·Urinary tract infection in a man with Parkinson's disease
An 84-year-old man with Parkinson's disease and dementia died from urinary tract infection with sepsis while incarcerated. On 3 November 2021, he developed fever and confusion; antibiotics were commenced. The following m…
56y · Male·Complications of clostridium difficile and malnutrition in the setting of cerebr…
Mr C was a 56-year-old man with cerebral palsy and acquired brain injury who died from complications of Clostridioides difficile infection and malnutrition. He was admitted to hospital on 21 January 2022 with diarrhoea, …
51y · Male·COVID-19 pneumonia
Suong Van Nguyen, a 51-year-old worker at a chicken processing plant, died from COVID-19 pneumonia during home isolation in August 2020. He tested positive on 31 July, reported shortness of breath on 2 August, then becam…
84y · Male·Respiratory failure complicating hospital acquired pneumonia following surgical …
An 84-year-old man died from respiratory failure due to hospital-acquired pneumonia following surgery for recurrent mandibular squamous cell carcinoma. Key clinical lessons: (1) Advanced Care Plans (ACPs) must be activel…
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