2,762 results
71y · Male·End-stage chronic obstructive pulmonary disease and atherosclerotic heart diseas…
Colin Albert Winter, a 71-year-old prisoner who died from end-stage COPD and atherosclerotic heart disease, received comprehensive medical care during 33 years of incarceration at Casuarina Prison. Key clinical lessons i…
72y · Female·Pneumonia following cervical spine injuries sustained in an unwitnessed mechanic…
Valma Ann Tweedie, aged 72, died from pneumonia following cervical spine injuries sustained in an unwitnessed fall at a disability support facility. She had a known history of falls, mobility problems, and probable demen…
3y · Male·Disseminated Staphylococcus aureus infection
A 3-year-old Aboriginal boy died from disseminated Staphylococcus aureus infection with sepsis. He presented to a remote clinic on 10 April with fever and dizziness, then returned on 13 April with irregular fever, lethar…
25y · Female·Injuries sustained in a single vehicle motor vehicle incident in which Ms Dent w…
Paige Dent, 25, died in a single-vehicle motor accident after absconding from hospital on 6 October 2018. She had a 19-year history of psychiatric admissions for schizophrenia, borderline personality disorder, and substa…
49y · Female·Hypoxic brain injury related to tracheostomy complications in form of airway occ…
Andrea Lester, age 49, suffered a subarachnoid haemorrhage from a PICA aneurysm in March 2018 with delayed diagnosis. Following complex neurosurgery causing Wallenberg syndrome, she required tracheostomy for bulbar dysfu…
50y · Male·ischaemic heart disease
Paul Reid, a 50-year-old Aboriginal man with severe ischaemic heart disease and poor medication compliance, died of a cardiac arrhythmia during his arrest by South Australian Police. He was highly intoxicated (BAC 0.25%)…
15y · Male·Neck compression due to hanging
Yakamurro, a 15-year-old First Nations boy in Territory Families care, died by hanging in NSW in December 2018. The coroner found multiple systemic failures contributed to his death. Key failures: inadequate family consu…
53y · Male·intracerebral haemorrhage
William Anderson, an Aboriginal man aged 53, suffered a catastrophic intracerebral haemorrhage while imprisoned and died despite timely emergency response. Multiple delays occurred: 25 minutes before the cell was opened,…
3y · Male·Hypoxic ischaemic encephalopathy complicating hypoglycaemia with shock and statu…
A 3-year-old boy with septo-optic dysplasia and panhypopituitarism died from hypoxic ischaemic encephalopathy secondary to adrenal crisis and hypoglycaemic shock. He was in state care and had an emergency management plan…
6y · Male·cardiopulmonary arrest on a background of earlier cardiac arrests and resuscitat…
Austin Facer, a 6-year-old boy, suffered multiple cardiac arrests at school on 21 October 2019, initially resuscitated successfully, but died during transfer preparation to a higher-level hospital that evening. Autopsy r…
30y · Male·Gunshot wounds to the chest
Gabriel Messo, a 30-year-old man with bipolar affective disorder, died from gunshot wounds inflicted by Victoria Police on 16 July 2020 after violently assaulting his mother at John Coutts Reserve. Clinical lessons inclu…
74y · Male·Pericarditis post aortic valve surgery with large pericardial effusion leading t…
Ian Dunlop, a 74-year-old man, died from pericarditis with large pericardial effusion and tamponade four days after aortic valve replacement surgery. Post-operative imaging showed a small pericardial effusion, considered…
58y · Male·complications of large bowel pseudo-obstruction
Paul Desmond Smith, aged 58, died from complications of large bowel pseudo-obstruction following discharge from hospital after inadequate assessment. He had presented to the ED with lower abdominal pain and severe faecal…
41y · Male·Gunshot wounds to the head and torso
Duy Linh Ho, a 41-year-old man with long-standing substance use disorder and untreated mental health issues, died from gunshot wounds after a police response to his self-harm and suicidal crisis. He had used methamphetam…
43y · Male·Hanging
William Epere, aged 43, died by hanging in custody at Dawn de Loas Correctional Centre on 10 January 2019. He had been remanded in custody for 27 days following repeated breaches of a domestic violence order, despite cle…
59y · Male·complications of viral liver cirrhosis with hepatocellular carcinoma
Mervyn Morgan, aged 59, died from complications of hepatocellular carcinoma arising from cirrhosis while in prison custody. Critical failures included: delayed monitoring of known liver cirrhosis (no ultrasound despite M…
46y · Male·Cold environmental exposure in a man with cardiomegaly
Carl Robert Adler, a 46-year-old man with treatment-resistant schizophrenia, intellectual disability, and autism, died from cold environmental exposure complicated by pre-existing cardiomegaly after leaving a community c…
44y · Male·gunshot wound to the abdomen
Vlado Micetic, 44, was fatally shot by Leading Senior Constable Timothy Baker during a traffic interception for stolen number plates in Windsor, Victoria, on 25 August 2013. Baker claimed Micetic produced a knife during …
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…
64y · Male·Peritonitis, due to or as a consequence of a ruptured gallbladder, due to or as …
Dennis Childs, a 64-year-old Indigenous man serving a life sentence, died from peritonitis secondary to a ruptured gallbladder. On 8 December 2018, he presented with abdominal pain at the correctional centre but refused …
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