292 results
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…
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, …
75y · Male·End stage myelodysplastic syndrome and end stage renal failure on a background o…
A 75-year-old man died in prison custody from end-stage myelodysplastic syndrome and renal failure on a background of ischaemic heart disease, hypertension, valvular disease, and metastatic prostate cancer. He was admitt…
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…
70y · Female·Heart failure due to paroxysmal atrial fibrillation treated with flecainide card…
A 70-year-old woman with complex cardiac history including heart failure, paroxysmal atrial fibrillation, and coronary atherosclerosis presented with urinary tract infection and atrial fibrillation on Christmas Day 2021.…
54y · Male·quetiapine toxicity in a man with ischaemic heart disease
Shane Pappas, a 54-year-old man with ischaemic heart disease, died from quetiapine toxicity after deliberately overdosing on multiple medications on 29 June 2021. He had experienced a recent relationship breakdown and pr…
44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…
Michael Baker, a 44-year-old Aboriginal man in custody at Lithgow Correctional Centre, died from cardiac arrhythmia on 25 June 2019. He had multiple comorbidities (hypertensive heart disease, obesity, type 2 diabetes, un…
49y · Male·Acute myocardial infarction complicating prosthetic valve thrombosis in a man wi…
Joshua Paul Coates, aged 49, died from acute myocardial infarction complicating prosthetic valve thrombosis following mechanical aortic valve replacement. Post-mortem examination revealed a large blood clot obstructing h…
37y · Male·Complications due to atherosclerotic heart disease and dyslipidaemia
Glen Dooley, a 37-year-old Aboriginal man, died of atherosclerotic heart disease and dyslipidaemia while in custody at Darwin Correctional Centre. His death was avoidable. He had abnormal ECGs in 2019 and 2022 that were …
35y · Male·cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory…
35-year-old Mohamed Warwar died in custody at Metropolitan Remand & Reception Centre from cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues an…
20y · Male·exertional heat stroke
A 20-year-old professional rugby league player collapsed and died from exertional heat stroke after his first pre-season training session following an extended off-season break. Keith had the lowest aerobic fitness of hi…
59y · Male·ischaemic heart disease in the setting of chronic ethanol use
Robert Spencer, 59, called 000 at 4:27 am reporting weakness and inability to mobilise following a fall. He was triaged as Code 3 (non-urgent) and underwent secondary triage call-back attempts without success. An ambulan…
11y · Male·unascertained
An 11-year-old child with Cornelia de Lange Syndrome and severe congenital heart disease died alone at home while his mother was intoxicated and unwell. He had complex care needs and was non-verbal. The Department of Com…
29y · Male·cardiac arrhythmia triggered by myocardial ischaemia arising from physical exert…
Brandon Rich, a 29-year-old Aboriginal man, died from cardiac arrhythmia triggered by myocardial ischaemia following a police struggle at his home. He had undiagnosed severe coronary artery disease (75-90% narrowing), mo…
39y · Female·Sudden cardiac arrhythmia following the administration of Kambo frog toxin
Natasha Lechner, a 39-year-old woman with chronic pain from degenerative disc disease, died from sudden cardiac arrhythmia triggered by Kambo frog toxin administration during a ceremony. She had completed Kambo practitio…
31y · Male·complications of infective exacerbation of bronchiectasis with cor pulmonale
A 31-year-old man with severe end-stage bronchiectasis and cor pulmonale died from acute infective exacerbation two days after arrest in police custody. Although he showed obvious signs of respiratory distress and heart …
43y · Male·The combined effects of subacute myocardial injury and methadone toxicity
Timothy Ricketts, a 43-year-old man with complex psychiatric and substance use history, died from combined subacute myocardial injury and methadone toxicity. He had been admitted to hospital in November 2021 with elevate…
68y · Male·Sudden cardiac death due to congestive cardiac failure and chronic obstructive p…
Wayne Victor Rouse, 68, died from sudden cardiac death at a residential aged care facility when CPR was not provided despite his active resuscitation order. Staff incorrectly believed he had a 'do not resuscitate' order …
40y · Male·coronary artery atherosclerosis
Shane Narrier, a 40-year-old Aboriginal man, died from coronary artery atherosclerosis on 5 June 2020 at Acacia Prison. On 27 May 2020, he reported chest pains via the Custody Messaging System (CMS) to a prison nurse. Th…
<1y · Male·hypoxia and reduced pulmonary perfusion complicating congenital heart disease
Logan Scott Fergusson, a 6½-week-old neonate with complex congenital heart disease (pulmonary atresia with ventricular septal defect), died from hypoxia and reduced pulmonary perfusion following surgery at the Royal Chil…
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