193 results
46y · Male·Aspiration pneumonia in an obese man with a history of diabetes mellitus, obstru…
Samuel Edward Ashby, a 46-year-old prisoner with treatment-resistant schizophrenia, died from aspiration pneumonia complicated by clozapine effect. Key clinical lessons: (1) smoking cessation dramatically increases cloza…
83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)
An 83-year-old male prisoner died from complications of a ruptured abdominal aortic aneurysm (AAA) after a 5-month delay in diagnostic confirmation and treatment. An incidental finding of an 8.7 cm AAA was identified on …
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…
29y · Male·Pulmonary thromboembolism secondary to deep venous thrombosis
A 29-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis (DVT) following a suicide attempt by hanging. He was admitted to ICU and appropriately commenced on prophylactic enoxaparin 40mg dai…
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, …
37y · Male·Pulmonary thromboembolus due to left leg deep vein thrombosis
A 37-year-old Aboriginal man died of pulmonary thromboembolism due to deep vein thrombosis while incarcerated. He presented to hospital on his birthday with lethargy, shortness of breath, and tachycardia. Initial assessm…
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
Maarouf El-Cheikh, a 57-year-old man with splenectomy history, presented to Calvary Hospital ED with sepsis on 21 March 2016 and died 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadeq…
82y · Male·bronchopneumonia
William Garnet Phillips, an 82-year-old widower with cardiac history, died from bronchopneumonia while frail and underweight (58 kg). He lived alone, was socially isolated, and refused all offers of assistance from famil…
74y · Male·Intra-abdominal haemorrhage complicating elective umbilical hernia repair
A 74-year-old man with significant cardiac history (atrial fibrillation, dilated cardiomyopathy, pacemaker) underwent elective umbilical hernia repair. Intraoperatively, unexpected ascites was discovered and partially dr…
72y · Female·subdural haemorrhage sustained from a fall from a hospital bed on 18 January 201…
Mrs Judith Gaye Flynn, aged 72, died from a subdural haemorrhage sustained when she fell from a hospital bed on the General Medicine Ward at Canberra Hospital. She was a high-risk fall patient with cognitive impairment, …
40y · Female·Complications of WHO Class III Obesity
Cindy Jane Martin, a 40-year-old Aboriginal woman with treatment-resistant schizophrenia, WHO Class III obesity, and obstructive sleep apnoea, died of sudden cardiac complications seven days after psychiatric admission. …
76y · Male·ischaemic heart disease following hyperglycaemic hyperosmolar syndrome (HHS) due…
Wayne Douglas Tedmanson, aged 76, died from ischaemic heart disease following hyperglycaemic hyperosmolar syndrome (HHS), a complication of type 2 diabetes mellitus. Clinical lessons include recognising HHS presentations…
41y · Male·haemothorax due to ruptured thoracic aortic aneurysm in a man with Marfan syndro…
A 41-year-old man with Marfan syndrome and a thoracic aortic aneurysm managed conservatively with blood pressure medications died from aneurysm rupture while imprisoned. Methylamphetamine in his system significantly elev…
44y · Male·Complications of a Left Temporal Lobe Abscess
Mootijah was a 44-year-old Aboriginal man who died from a brain abscess originating from an untreated chronic ear infection. He had documented hearing impairment and a history of chronic ear disease requiring ENT special…
57y · Male·Consequences of multiple injuries (from fall from elevated walkway)
Mladen Jovanoski, a 57-year-old remand prisoner, died from head injuries sustained after falling from a prison walkway on 11 April 2018. He had suspected metastatic thyroid cancer requiring urgent biopsy at a tertiary ho…
75y · Male·Multiorgan dysfunction syndrome complicating anastomotic leak following hemicole…
A 75-year-old man died from multiorgan dysfunction following an anastomotic leak after hemicolectomy for caecal adenocarcinoma. Initial post-operative recovery appeared normal, but he deteriorated from day 3 onwards. The…
53y · Male·multiple injuries sustained in a fall from the first floor
Kelvin Forrest, a 53-year-old man with Down syndrome and dementia, died from multiple injuries sustained in a fall from the first floor of Byron Central Hospital on 28 July 2018. He had been admitted as a medical patient…
80y · Male·metastatic oesophageal cancer
Josef Lear, an 80-year-old prisoner, died of metastatic oesophageal cancer at the Royal Darwin Hospital Hospice on 7 March 2021. He presented with progressive dysphagia, cough, and weight loss in mid-2020, which was appr…
54y · Female·unascertained
Carole Livesey, a 54-year-old woman with severe anorexia nervosa and major depression, absconded from Rockingham Hospital psychiatric unit on 3 October 2017 during an escorted walk in hospital grounds. She had been an in…
Male·Complications of alcohol and hepatitis C-related liver disease
Peter Young, an Aboriginal man with advanced alcoholic cirrhosis and recently acquired hepatitis C infection, died of multi-organ failure while on remand in custody. He received appropriate standard medical care in priso…
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