2,762 results
1y · Female·infarction and volvulus of the small intestine due to adhesion from prior nephre…
A 19-month-old girl with history of Wilms tumour presented to Launceston General Hospital with vomiting, pain and lethargy. A Children's Early Warning Tool score of 6 triggered mandatory protocols including senior doctor…
2y · Female·perforated oesophagus secondary to complications of treatment of oesophageal inj…
Callie Griffiths-I'Anson, a 2-year-old girl, died from a perforated oesophagus secondary to complications of treatment for caustic soda ingestion. She ingested caustic dishwashing liquid at a hotel on 11 December 2017 an…
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…
62y · Male·Severe crush injuries sustained when struck by the boom of an overturned crane
Herman Holtz, a 62-year-old tower crane operator, died on 4 August 2016 when crushed by an overturned mobile crane at a university construction site. The crane operator, inadequately trained and unfamiliar with the site,…
27y · Male·Mixed drug (methylamphetamine and clozapine) toxicity
KT, a 27-year-old with treatment-resistant schizophrenia, died in custody from mixed drug toxicity (clozapine and methylamphetamine). He was prescribed appropriate clozapine treatment with adequate monitoring. Key failur…
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…
17y · Male·Circulatory failure caused by traumatic brain injury from being struck by a log
Christiaan Adriaan Roodt, a 17-year-old Year 10 student, died from traumatic brain injury when struck by a 6-metre log during a 'Capture The Flag' game at Mount Ainslie, near his school. Key clinical lessons: (1) The ina…
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…
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 …
41y · Male·Gunshot and shrapnel wounds to the body (SC Forte); Gunshot wound to the chest a…
Senior Constable Brett Forte was fatally shot by Ricky Maddison during a police pursuit in rural Queensland on 29 May 2017. Maddison, a high-risk domestic violence offender wanted on multiple warrants, had evaded police …
46y · Male·atherosclerotic heart disease
Frank Albert, a 46-year-old Aboriginal man, died from atherosclerotic heart disease while incarcerated at West Kimberley Regional Prison. Although his death was caused by severe coronary artery disease unrelated to medic…
71y · Male·Acute myeloid leukaemia due to transformation from chronic myelomonocytic leukae…
Peter Timms, a 71-year-old prisoner with multiple comorbidities, died from acute myeloid leukaemia (AML) transformed from chronic myelomonocytic leukaemia. He made over 40 health service requests while incarcerated, incl…
63y · Male·Hypoxic ischaemic brain injury and pneumonia complicating cardiac arrest in a ma…
Armin Schaefer, a 63-year-old man with schizophrenia, cardiac risk factors, and emphysema, died from hypoxic-ischaemic brain injury and pneumonia following cardiac arrest on a psychiatric unit. He presented to ED on 15 A…
79y · Male·complications of peritonitis
A 79-year-old man with multiple comorbidities presented with a perforated bowel requiring emergency Hartmann's procedure. The operating surgeon, Dr L.-Ming Schmidt, made a catastrophic surgical error by exteriorising the…
23y · Female·Hypoxic-ischaemic brain damage due to self-inflicted hanging with intention of t…
Brontë Haskins, aged 23, died by suicide via hanging on 18 February 2020, three days after her release from custody on bail. The inquest identified multiple systemic failures in supervision, assessment, and coordination …
27y · Male·hanging
A 27-year-old man with deteriorating mental health and acute psychotic symptoms died by hanging from a bathroom door in an acute mental health unit. He had expressed suicidal ideation, told his parents he needed to die t…
25y · Male·Dehydration with contributory causes of severe mental health conditions and hype…
Darren Higgins, a 25-year-old Wiradjuri man with treatment-resistant schizophrenia and polysubstance abuse disorder, died from dehydration and hyperthermia in Moira State Forest after absconding during escorted weekend l…
16y · Male·cardiac arrhythmia or hypoxia in the setting of hydrocarbon inhalation
Bradley Hope, 16, died from cardiac arrhythmia or hypoxia following inhalation of hydrocarbon propellants from an aerosol deodorant purchased at a supermarket self-checkout. After engaging in volatile substance use with …
Female·haemopericardium due to aortic dissection (all three cases)
Three elderly women died from acute aortic dissection at Queen Elizabeth Hospital, South Australia. Beverley Coats (73) presented three times in July 2016 with back pain, nausea and vomiting; her known aortic dilatation …
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…
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