125 results
53y · Male·lung abscess with empyema
A 53-year-old man with schizophrenia died from lung abscess with empyema while an involuntary inpatient at a mental health facility. He had been readmitted with a respiratory infection and was treated with intravenous an…
56y · Male·acute exacerbation of chronic obstructive pulmonary disease (bronchial asthma) i…
Ashley Adrian Lane, a 56-year-old Aboriginal man from the Ngaanyatjarra Lands, died in custody at Kalgoorlie Regional Hospital from acute exacerbation of chronic obstructive pulmonary disease (asthma). He was a remand pr…
50y · Male·Gunshot wounds to the chest
Mark Sheppard, aged 50, died from gunshot wounds sustained during a police response to a hoax emergency call at a caravan park. He had terminal end-stage COPD with alpha-1 antitrypsin deficiency and was using home oxygen…
51y · Female·Aspiration pneumonia
A 51-year-old woman with Sturge-Webber syndrome and poor swallowing ability presented to hospital with a cough and was admitted on 15 December 2017, following a choking incident at her group home. She died on 23 December…
70y · Male·complications of chronic obstructive pulmonary disease and ischaemic heart disea…
A 70-year-old man with end-stage COPD, ischaemic heart disease, and obstructive sleep apnoea collapsed in his prison cell and was transferred to hospital in respiratory distress. Despite having documented 'not for resusc…
36y · Male·Complications of morbid obesity, including cardiac enlargement, aspiration of ga…
A 36-year-old man with treatment-resistant schizophrenia and Capgras syndrome died from complications of morbid obesity (183.5 kg, BMI 45.3). He was discharged from hospital on 14 January 2019 after admission for respira…
69y · Male·Myocardial infarction secondary to coronary artery atherosclerosis in the settin…
Mr Crabtree, a 69-year-old man with intellectual disability, COPD, emphysema and heavy smoking history, presented to the ED with respiratory distress on 26 May 2016. He was diagnosed with infective exacerbation of COPD a…
78y · Male·cardiorespiratory failure due to complications of tracheal stenosis
Bruce Hodges, a 78-year-old man with a 20-year-old tracheostomy following laryngeal cancer surgery, presented to hospital with progressive shortness of breath and tracheal stenosis. Over 48 hours of admission, his respir…
73y · Male·Disseminated malignancy (advanced lung carcinoma and mouth carcinoma) in a man w…
Robert Craig, aged 73, died from disseminated malignancy (advanced lung and mouth carcinoma) while in prison custody. He received suboptimal cancer treatment at Fiona Stanley Hospital due to communication failures betwee…
38y · Male·Mixed drug toxicity
DA was a 38-year-old man who died from mixed drug toxicity involving sedating medications and alcohol. He had longstanding severe anxiety and became dependent on codeine and benzodiazepines, initially obtained from multi…
38y · Male·combined effects of acute-on-chronic respiratory disease and cardiomegaly
Marshall Ruben Edgill, a 38-year-old Indigenous man, died in custody from acute-on-chronic respiratory disease and cardiomegaly. He had longstanding obstructive sleep apnoea (OSA), obesity, asthma, and hypertension. Crit…
15y · Unknown·acute respiratory distress syndrome resulting from multi-organ failure as a cons…
Child A, aged 15, died from acute respiratory distress syndrome resulting from multi-organ failure due to disseminated tuberculosis. He presented to hospital with very advanced post-primary pulmonary tuberculosis requiri…
34y · Female·Pneumonia in a woman with intellectual disability and asthma
Simone Grigg, a 34-year-old woman with intellectual disability and asthma, died from pneumonia. She was living in DHHS supported accommodation and attending Amicus day services. On 21 November 2017, she developed respira…
81y · Female·Aspiration pneumonia in an elderly lady
An 81-year-old woman with intellectual disability, phenylketonuria, and severe dysphagia died from aspiration pneumonia following repeated admissions for the same condition. She had been assessed as 'very high risk of as…
61y · Male·Hypoxic encephalopathy arising from cardiac arrest following self-removal of a c…
Kelvin Moulds, a 61-year-old man, died of hypoxic encephalopathy following a cardiac arrest caused by self-removal of a central venous catheter (CVC) on day 14 post-bilateral lung transplant. The CVC was still in situ de…
36y · Male·bronchial asthma
Nathan Reynolds, a 36-year-old Aboriginal man with severe asthma, died from bronchial asthma in prison on 1 September 2018. His death exposed critical failings in both immediate emergency response and chronic disease man…
24y · Female·Cardiac conducting system disease leading to asystole against a background of a …
A 24-year-old woman with complex congenital cardiac disease, cerebral palsy, and hydrocephalus was admitted to a secondary hospital with a respiratory tract infection and bradycardia with left bundle branch block. She de…
70y · Male·carcinoma of the lung
Stuart Dugan, a 70-year-old prisoner with advanced lung cancer, died in hospice care. He had multiple missed opportunities for earlier diagnosis. While smoking-related lung cancer commonly presents late with poor prognos…
58y · Male·Metastatic non-small cell lung carcinoma
Barry Haynes, a 58-year-old Aboriginal man, died of metastatic non-small cell lung carcinoma while on remand in custody. He had stage 4 lung cancer with brain metastases diagnosed in November 2016, shortly before his arr…
76y · Female·pulmonary embolism due to carcinomatosis
A 76-year-old woman presented to hospital with shortness of breath and was initially diagnosed with community-acquired pneumonia and later pulmonary oedema. Both diagnoses were incorrect. She had widespread cancer (carci…
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