57 results
70y · Male·metastatic gastric adenocarcinoma
A 70-year-old man with prior bladder cancer was undergoing routine CT surveillance. Stomach cancer signs were clearly visible on February 2017 and February 2018 CT scans but failed to be detected by consulting radiologis…
83y · Male·Metastatic melanoma
Maxwell John Beever, aged 83, died from metastatic melanoma on 8 July 2022 while in custody at Robina Hospital. A suspicious skin lesion was documented on 26 February 2021 but not investigated until 26 June 2021, delayin…
53y · Male·Metastatic pancreatic carcinoma
Michael Sanderson, a 53-year-old Gamilaroi man, died from metastatic pancreatic cancer while in custody. Critical clinical lessons emerge: (1) failure to review pathology results within required 14-day timeframe delayed …
82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis
An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was …
61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed
A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…
71y · Female·complications of metastatic endometrial carcinoma, treated palliatively
Corazon Contreras Keeley, a 71-year-old woman with postmenopausal bleeding, was investigated for possible endometrial cancer. Dr K. performed a hysteroscopy with dilation and curettage (HDC) on 29 November 2019, observin…
76y · Male·small bowel obstruction in the setting of terminal metastatic neuro-endocrine tu…
A 76-year-old Aboriginal man died of small bowel obstruction from metastatic neuro-endocrine tumour after spending nearly two years requesting medical help in prison without receiving a doctor's review. Between October 2…
76y · Female·Effects of fire in a woman with head and neck injuries
Mrs Emma Weidemann, aged 76, died from burns sustained in a fire deliberately set by her husband Rudolf at their home on 11 December 2019. Rudolf had recently been diagnosed with terminal cancer, experienced cognitive de…
36y · Male·T-Lymphoblastic Leukaemia/Lymphoma (T-ALL)
Matthew Biggin, a 36-year-old man with severe intellectual disability, died from T-lymphoblastic leukaemia after a 5-month illness. In August 2021, he presented with cough, throat pain and fatigue but was not fully asses…
71y · Male·Complications of metastatic squamous cell carcinoma (terminal palliation)
Leslie Shortte, a 71-year-old life prisoner, died from metastatic squamous cell carcinoma with complications. Critical failures in his prison medical care included: failure to complete annual health assessments after 201…
56y · Female·sepsis secondary to disseminated pancreatic adenocarcinoma
Julie Michele Dunn, a 56-year-old female prisoner, died of sepsis secondary to disseminated pancreatic adenocarcinoma. She had presented months earlier with gastrointestinal symptoms (weight loss, nausea, vomiting, epiga…
69y · Male·Hypoxic ischaemic brain injury secondary to right facial artery pseudoaneurysm r…
69-year-old male with tonsillar squamous cell carcinoma presenting with throat pain and trismus 12 days after completing chemoradiotherapy. On presentation to emergency department with bleeding, airway risk was under-rec…
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…
94y · Female·Complications of metastatic lobular carcinoma of the breast in a woman with deme…
A 94-year-old woman with advanced dementia and metastatic breast cancer died from complications of her malignancy. She presented repeatedly with vomiting due to duodenal obstruction from metastatic tumour, but this was n…
52y · Female·Neutropenic sepsis leading to multi-organ failure due to capecitabine toxicity
Mrs L, a 52-year-old woman with T2N0M0 rectal cancer, died from neutropenic sepsis and multi-organ failure secondary to severe capecitabine toxicity on 31 October 2018. She commenced neoadjuvant chemotherapy with capecit…
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…
75y · Male·cerebral metastatic malignancy (lung cancer with brain metastases)
Kenneth Ballard, aged 75, died in prison custody from cerebral metastatic lung cancer. He had been diagnosed with chronic lymphocytic lymphoma in 2012 and managed at Mount Gambier Prison. In late 2014, Mr Ballard refused…
56y · Male·aspiration pneumonitis secondary to airways obstruction from squamous cell carci…
Edgar Forrester, a 56-year-old Aboriginal man, died of aspiration pneumonitis secondary to oesophageal squamous cell carcinoma with metastases while in custody. He presented with progressive dysphagia from September 2019…
47y · Male·Complications of cirrhosis and metastatic hepatocellular carcinoma
Lance Robert Nikkelson, a 47-year-old Aboriginal man in prison custody, died from complications of cirrhosis and metastatic hepatocellular carcinoma. He presented with abdominal pain in May 2019, initially assessed as co…
73y · Male·metastatic carcinoma of the lung with palliation
Norman Hazelgrove, a 73-year-old prisoner, died from metastatic lung carcinoma in September 2017. Early in his imprisonment (2013), a chest X-ray showed COPD but this diagnosis was not formally documented or managed desp…
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