28 results
48y · Male·cardiac arrhythmia which occurred in the context of physical exertion and hypoxi…
Phillip Walton, a 48-year-old with schizophrenia well-managed on clozapine for nearly 20 years, suffered an acute psychotic episode likely precipitated by cannabis use at a circus. After aggressive behaviour requiring po…
55y · Male·Complications of alcohol use disorder
Dushyanthan Visvanathan, a 55-year-old man with alcohol use disorder and prior withdrawal seizure, died in custody at MRRC from complications of alcohol use disorder. Critical failures in clinical care included: inadequa…
83y · Female·Pulmonary thromboembolism due to aortic stenosis (recent transcatheter aortic va…
An 83-year-old woman with severe aortic stenosis, atrial fibrillation, and heart failure died from pulmonary embolism one day after discharge following transcatheter aortic valve replacement (TAVI). Clinical lessons cent…
81y · Male·Carcinoid tumour (metastasis) / metastatic cancer
Donald Richard Gunthorpe, an 81-year-old man with metastatic rectal carcinoma, was appropriately transitioned to end-of-life (palliative) care at a residential aged care facility after hospitalisation for abdominal pain.…
27y · Male·Neck compression due to self-inflicted hanging
Matthew Grieve, a 27-year-old first-time inmate with anxiety, depression and panic disorder, died by self-inflicted hanging in custody after eight days without prescribed medication. Critical failures included: an unsign…
26y · Male·hanging, intentionally self-inflicted
A 26-year-old Aboriginal man died by suicide in custody following discharge from a Risk Intervention Team (RIT) management plan on 19 October 2021. He had self-harmed on 17 October, reporting voices telling him to cut hi…
24y · Male·Neck compression in the circumstances of hanging
Boe Luke Memery, a 24-year-old Aboriginal man, died by hanging on 19 May 2019 following a relationship breakdown. He had a history of depression, self-harm, and previous suicide attempts. In the weeks before his death, h…
36y · Male·Cardiorespiratory arrest complicating propofol administration for endodontic pro…
Michael Anderson, a 36-year-old obese man (BMI 38.5), suffered cardiorespiratory arrest during a root canal procedure under conscious sedation with propofol administered by Dr S. in a dental office setting. He had undiag…
76y · Male·Intracranial Haemorrhage Secondary to Blunt Head Trauma (Fall) in the Setting of…
A 76-year-old man with newly diagnosed chronic myeloid leukaemia in blast crisis was admitted to hospital with sepsis and pancytopenia from chemotherapy. He suffered multiple falls while confused from sepsis, sustaining …
45y · Female·Hanging
A 45-year-old woman with bipolar affective disorder, borderline personality disorder, anorexia nervosa and depression died by hanging. She had chronic suicidal ideation and was managed in the community by a mental health…
75y · Male·Right haemothorax complicating intercostal catheter insertion for the treatment …
Giuseppe Costa, 75, died from right haemothorax following intercostal catheter insertion for pleural effusion drainage. Critical failures in clinical management included: inadequate documentation of pleural fluid drainag…
80y · Male·complications of necrotising pancreatitis secondary to pancreatic biopsy (EUS)
John Twycross, an 80-year-old man with a history of hypertension, asthma, glaucoma and prior cholecystectomy, presented with acute pancreatitis in April 2011 after imaging revealed a suspected ampullary carcinoma. Follow…
69y · Female·unascertained
Christine Pearl Stroner, 69, died of an unascertained cause on the evening of discharge following laparoscopic cholecystectomy and hiatus hernia repair at Fremantle Hospital. She was observed at 2pm with tachycardia (HR …
55y · Female·Cardiac tamponade due to haemopericardium due to acute ruptured myocardial infar…
A 55-year-old woman with extensive coronary artery disease presented for elective stent placement to her left anterior descending artery. During the procedure, a small diagonal branch vessel was occluded—a recognised com…
67y · Male·Faeculent peritonitis due to perforation of a sigmoid volvulus
Ross Butler, a 67-year-old with dementia and Parkinson's disease, presented with abdominal pain and decreased appetite. A sigmoid volvulus was identified and a rectal tube successfully inserted for decompression. Conserv…
62y · Male·Global cerebral ischaemia secondary to intra-operative hypotension following the…
A 62-year-old man died from global cerebral ischaemia following intra-operative hypotension after protamine administration during a cardiac ablation procedure. He had suffered a severe hypotensive reaction to protamine 8…
77y · Male·Subarachnoid and subdural haemorrhage post head trauma secondary to a fall
Leslie Alexander, 77, died from subarachnoid and subdural haemorrhage following a fall at an aged care facility. He fell on 29 March and again on 30 March 2015, striking his head. Initial assessment by a locum GP found n…
63y · Male·Hypotensive and atherosclerotic heart disease
A 63-year-old male prisoner with Type II diabetes, hypertension, obesity and coronary atherosclerosis died of cardiac arrhythmia while engaged in farm work at a minimum-security prison. Dr L. provided acceptable diabetes…
54y · Female·multiple injuries sustained in head-on motor vehicle collision
Yvonne Henderson, a 54-year-old with chronic delusional disorder, died in a head-on motor vehicle collision on 6 December 2010 while on approved leave from involuntary psychiatric admission. She was driving her van on th…
80y · Male·Drowning
An 80-year-old man with severe depression, suicidal ideation, and probable vascular dementia died by drowning after leaving a psychiatric ward. He was appropriately treated with ECT, medication, and placed on an ITO. How…
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