186 results
92y · Male·unascertained
A 92-year-old man with advanced dementia died in aged care following an unwitnessed fall on 3 December 2021. He deteriorated rapidly after a second fall at 11:45pm and died shortly after. The precise cause of death remai…
85y · Female·Complications of a left ankle fracture (operated)
An 85-year-old woman with multiple comorbidities (diabetes, ischaemic heart disease, hypertension, prior stroke) sustained a left ankle fracture requiring surgical repair. A significant delay occurred in removing her pla…
83y · Female·meningitis with sepsis with the likely source of infection being a large and dee…
Dorothy Jean Atkins, aged 83, died on 9 July 2017 from meningitis and sepsis secondary to a large stage 4 sacral decubitus ulcer. Autopsy revealed severe malnutrition (24.5kg, BMI 13), poor hygiene with faecal soiling un…
92y · Female·Consequences of an assault
A 92-year-old woman with dementia died from consequences of an assault by another resident with unmanaged psychosis in an aged care facility. The assault occurred after the facility failed to adequately monitor, assess, …
98y · Male·comminuted pertrochanteric fracture of left hip sustained in mechanical fall
A 98-year-old man with osteoporosis, dementia, and ischaemic heart disease sustained a comminuted pertrochanteric hip fracture in a fall at his residential aged care facility on 24 July 2023, dying four days later. He ha…
74y · Female·Fractures of the legs, with terminal palliative care, in an elderly lady with mu…
Ms Papanastasiou, a 74-year-old aged care resident confined to a wheelchair, died from bilateral femoral fractures sustained when she fell from her wheelchair during sudden bus braking. The wheelchair was secured using o…
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 …
66y · Male·unascertained (differential diagnosis: chronic alcoholism with alcohol withdrawa…
Colin Norman, a 66-year-old man with significant disability from traumatic brain injury, chronic alcoholism and liver cirrhosis, died at home after failing to receive essential disability support services over a weekend.…
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 …
73y · Male·unknown
A 73-year-old man with dementia and frontal lobe impairments disappeared from a nursing home on 5 January 2018; his remains were discovered a year later in a nearby river. Critical clinical and organisational failures oc…
89y · Female·Complications of fractured neck of femur in the setting of a fall in a woman wit…
An 89-year-old woman with dementia and high falls risk sustained a fall at an aged care facility on 24 August 2019. The enrolled nurse in charge, on her third unsupervised shift, lacked electronic medical record access a…
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…
88y · Female·Complications of a stage 3 sacral pressure ulcer in a woman with dementia
Margaret Alice Cook, an 88-year-old woman with end-stage dementia, died from complications of a stage 3 sacral pressure ulcer at a palliative care unit. She had resided at Crofton House Supported Residential Services (SR…
78y · Male·Not determined - no remains found, no postmortem examination possible
Luis Fernandez, 78, was reported missing on 1 January 2019 after last being seen on 28 December 2018 near Glenfield station. The coroner found he is now deceased but cannot determine the place, cause, or manner of death …
76y · Male·Streptococcus pneumoniae sepsis in the setting of acute bronchopneumonia and ren…
Terence Michael Brooks, a 76-year-old man with dementia, vascular disease, and depression, died of streptococcal pneumoniae sepsis with acute bronchopneumonia and renal failure from obstructive uropathy at an aged care f…
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…
81y · Male·pneumonia due to traumatic internal bleeding of the chest wall sustained in fall…
An 81-year-old man with Parkinson's disease, dementia, and multiple comorbidities residing in aged care suffered an unwitnessed fall on 6 June 2021, sustaining a right-sided chest wall haematoma. Staff found him at 7:40a…
83y · Female·Hospital-acquired pneumonia caused by injuries from fall; frailty and osteoporos…
An 83-year-old woman died from hospital-acquired pneumonia following spinal fractures sustained in a fall from a mobility hoist at an aged care facility. The hoist failed when the spreader bar detached due to a worn and …
74y · Female·Diabetic ketoacidosis
A 74-year-old woman with Type 1 diabetes died from diabetic ketoacidosis (DKA) in an aged care facility. Between 7-10 December 2016, her blood glucose levels remained persistently elevated (>33 mmol/L) despite escalating…
73y · Male·Infectious Exacerbation of Chronic Obstructive Airways Disease with the Contribu…
Mr H, a 73-year-old man with chronic obstructive airways disease and Lewy body dementia, was admitted to hospital on 6 January 2021 following a psychiatric incident and was found to have pneumonia and severe infection. H…
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