186 results
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
84y · Male·The available evidence does not allow for any finding to be made as to the cause…
An 84-year-old man with Alzheimer's dementia and a history of wandering left his home on 15 September 2017 and was never found alive. The coroner determined he is deceased, likely died within days of going missing in bus…
84y · Male·Complications of fracture left humerus neck due to fall due to hyperactive delir…
An 84-year-old man with Alzheimer's disease and dementia-related behaviours developed a urinary tract infection causing acute delirium, atrial fibrillation, and multiple falls. After presenting to the emergency departmen…
88y · Female·Acute on chronic renal failure due to dehydration on a background of Lewy body d…
An 88-year-old woman with Lewy body dementia, Parkinson's disease and congestive cardiac failure died from acute kidney injury precipitated by severe dehydration in aged care. June 2020 blood tests showed mild hypernatra…
45y · Male·Environmental exposure and dehydration
A 45-year-old Aboriginal man with severe cognitive impairment (6.5-year-old equivalent English comprehension), traumatic brain injury, epilepsy and multiple medical conditions died from environmental exposure and dehydra…
87y · Female·right thigh haematoma as a consequence of a periprosthetic fracture of the right…
An 87-year-old woman with multiple comorbidities (diabetes, atrial fibrillation, peripheral vascular disease) sustained a periprosthetic fracture requiring distal femur replacement. She deteriorated significantly during …
39y · Male·Mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) with contribut…
Kevin Thomas Maloney, a 39-year-old man with complex mental health conditions and substance use disorder, died from mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) while residing in a supported resident…
Male·Little Brother: multi-organ dysfunction due to hypothermia with contributing con…
Two Aboriginal brothers with chronic alcohol use disorder and cognitive impairment died in July and September 2023 in Alice Springs Hospital. Both had adult guardianship orders, NDIS packages, and aged care assessments r…
65y · Female·Combined effects of acute pneumonia, pancreatitis, urinary tract infection, and …
A 65-year-old woman with chronic alcohol use disorder, multiple comorbidities, and progressive functional decline died from combined effects of pneumonia, pancreatitis, urinary tract infection, and severe pressure ulcers…
86y · Female·Hypostatic pneumonia due to the consequences of a right pubic rami fracture and …
An 86-year-old woman with advanced dementia and frailty suffered an unwitnessed fall at her aged care facility. Initial assessment failed to identify pubic rami and hip fractures. Post-fall documentation was insufficient…
74y · Male·Sepsis secondary to infected pressure wounds (necrotising fasciitis) in a man wi…
A 74-year-old man with multiple comorbidities (diabetes, obesity, respiratory failure, mental health conditions) died from sepsis secondary to necrotising fasciitis of pressure wounds developed while in aged care. Key cl…
54y · Male·Complications of pelvic and spinal fractures sustained in a fall in man with Dow…
Andrew William Barr, a 54-year-old man with Down syndrome and Alzheimer's dementia, died from complications of pelvic and spinal fractures sustained in a fall. Following his mother's death in January 2021 and his Februar…
57y · Female·starvation due to insufficient food intake
Patricia Iliev, a 57-year-old woman, died from starvation after progressively restricting her food intake over months while immobilised by chronic back pain. She had a gastrointestinal stromal tumour and advanced lung di…
86y · Male·Complications of blunt force trauma in a man with cardiac amyloidosis and athero…
An 86-year-old man with dementia, cardiac amyloidosis and atherosclerotic cardiovascular disease died from complications of blunt force trauma sustained in an assault by his adult son. The deceased had been diagnosed wit…
78y · Female·Complications of prolonged immobility and malnutrition in a woman with retroperi…
A 78-year-old woman with schizophrenia, depression, and undiagnosed retroperitoneal lymphoma died from septic shock complicating severe pressure ulcers, malnutrition, and dehydration. She had been immobile on a couch for…
89y · Female·Acute upper airway obstruction by food bolus
An 89-year-old woman with dementia died from acute upper airway obstruction by food bolus while being fed lunch at an aged care facility. CCTV footage revealed significant discrepancies between reported actions and actua…
87y · Female·Terminal exacerbation of chronic obstructive pulmonary disease; antecedent cause…
Maureen 'Kitty' McDonald, 87, died from terminal exacerbation of COPD with an antecedent sacral pressure wound infection. She was admitted to residential aged care in October 2020 with a stage-two sacral pressure injury …
84y · Male·Head injury - left lateral convexity acute subdural haematoma with 2mm midline s…
An 84-year-old man with Parkinson's disease and moderate dementia was admitted to a rehabilitation unit after a fall at an acute hospital. He had been assessed as high falls risk and required a patient sitter at the acut…
95y · Female·Acute intracranial haemorrhage
DRF, a 95-year-old woman with dementia, hearing impairment, mobility limitations, and mild cognitive impairment, died from acute intracranial haemorrhage following blunt head trauma. She had been living with her son UJN,…
71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation …
A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxon…
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