123 results
71y · Female·Diffuse Lymphoid Malignancy
Mary Una Barnett, a 71-year-old woman in custody at Dame Phyllis Frost Centre, died from diffuse lymphoid malignancy (high-grade lymphoma) discovered shortly before her death. She had extensive comorbidities including ch…
62y · Male·Non-small cell lung carcinoma with metastases
Desmond Sims, a 62-year-old prisoner, died from advanced non-small cell lung carcinoma with metastases. He was diagnosed with lung cancer in February 2009 at Princess Alexandra Hospital (PAH) but was lost to follow-up fo…
84y · Male·respiratory failure due to hospital-acquired pneumonia
Ronald Geoffrey Weeks, aged 84, died of respiratory failure due to hospital-acquired pneumonia following a hip fracture sustained in a fall at James Nash House psychiatric facility. He was serving an 8-year sentence for …
88y · Female·pulmonary thromboembolism due to fractured right femur due to a fall
Cynthia Thoresen, 88-year-old woman with dementia and osteoporosis, fell at home and sustained a fractured femur approximately three weeks before admission. Her daughter, the registered carer, failed to seek medical atte…
58y · Male·Respiratory failure due to or as a consequence of Chronic Obstructive Pulmonary …
Geoffrey Hornby, a 58-year-old prisoner with significant COPD, ischemic heart disease, and multiple comorbidities, died from respiratory failure secondary to COPD. He was admitted to hospital with COPD exacerbation and d…
Unknown·Ms Fensom: influenza A (H1N1 2009, pandemic swine flu) with myocarditis causing …
Two deaths from H1N1 influenza in 2009. Ms Fensom (41) died from myocarditis complicating swine flu after inadequate recognition and management of persistent hypotension at Millicent Hospital. Her condition required esca…
75y · Male·Unascertainable due to advanced decomposition; likely lung cancer
Robert Roll, a 75-year-old socially isolated pensioner with terminal lung cancer, discharged himself from Royal Perth Hospital on 6 July 2009 against planned palliative care arrangements. Although Silver Chain Hospice ar…
45y · Female·Aspiration pneumonia
A 45-year-old woman with Down syndrome, epilepsy, and non-verbalisation living in a high-care community residential facility died from aspiration pneumonia. She developed cold/flu symptoms on 2 January 2011, with a cough…
54y · Female·Multi-organ failure following a decreased level of consciousness caused by compl…
Linda Christina Mulvaney, 54, died of multi-organ failure following a prolonged period of unconsciousness caused by a combination of obstructive and central sleep apnoea complicated by sedating substances. On 2 June 2008…
56y · Male·disseminated nocardiosis involving central nervous system, kidneys, liver and th…
Allan Kenneth Miller, 56, died from disseminated nocardiosis (rare bacterial infection) that was not diagnosed during his 12-day RAH admission. Clinicians initially suspected metastatic lung cancer based on presentation …
Multiple: pneumonia with cardiomyopathy (Kugena female); septic shock from pneum…
Concurrent coronial inquests into six Aboriginal deaths in Ceduna, South Australia between 2004-2009. All deceased had severe alcohol addiction and comorbidities including pneumonia, cardiomyopathy, liver disease, and se…
16y · Female·obstructed breathing and heart arrhythmia secondary to severe obstructive sleep …
A 16-year-old Aboriginal girl with severe obstructive sleep apnoea died unexpectedly in her home one week before scheduled surgery. She had been symptomatic since age 13, but surgery was delayed for four years due to mul…
63y · Male·Metastatic carcinoma of the lung
Lawrence Jeffrey, a 63-year-old inmate at Lotus Glen Correctional Centre, died from metastatic lung carcinoma on 11 May 2008. He presented with symptoms consistent with his known chronic conditions (asthma, COPD, silicos…
54y · Female·Sepsis due to bronchopneumonia complicating malignant spindle cell tumour of rig…
Jennifer Gibbins, a 54-year-old woman with non-verbal communication disability living in supported accommodation, presented with recurrent cough from April 2005. Initial management consisted of antibiotics prescribed by …
47y · Male·abnormal heart rhythm (arrhythmia) induced by atherosclerosis, occurring in the …
Peter Shishko, a 47-year-old man with bipolar affective disorder, died in a mental health facility while in involuntary detention. He suffered a fatal cardiac arrhythmia on a background of severe coronary atherosclerosis…
17y · Male·fatal asphyxia resulting from severe upper airway obstruction secondary to acute…
Kieran Watmore, a fit 17-year-old male, died from fatal asphyxia at Albany Regional Hospital on 28 August 2008 while being treated for acute tonsillitis. He presented to ED on 27 August with severe throat pain and was pr…
65y · Female·gastrointestinal haemorrhage from duodenal ulcer
Margaret Bodell, 65-year-old with severe COAD and emphysema, was admitted with respiratory failure and developed a duodenal ulcer bleeding during hospitalisation. Critical clinical lessons include: (1) careful oxygen man…
23y · Female·Pulmonary barotrauma due to or as a consequence of a scuba diving accident
Maren Lyndsey Dell, 23, died during a resort dive at Agincourt Reef from pulmonary barotrauma caused by rapid ascent from 9 metres. She panicked when unable to clear water from her mask and ascended quickly without expel…
64y · Female·Respiratory arrest secondary to morphine overdosage on a background of mild to m…
A 64-year-old woman died from respiratory arrest secondary to morphine overdose after ingesting 17 tablets of slow-release morphine (Kapanol) and diazepam. Initial emergency assessment by an intern was appropriate, but c…
60y · Female·haemorrhagic shock and respiratory failure due to right-sided haemothorax compli…
A 60-year-old woman with metastatic breast cancer and COAD died from haemorrhagic shock due to right-sided haemothorax complicating thoracentesis. The procedure was appropriately performed to drain a pleural effusion on …
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