338 results
77y · Female·Ischaemic heart disease
Gayle Patricia Carley, 77, collapsed unwitnessed at home with acute ischaemic heart disease on 19 October 2023. Ambulance paramedics arrived and initiated emergency treatment, but a MICA paramedic inadvertently administe…
94y · Female·Drug toxicity (baclofen, gabapentin, oxycodone, pregabalin, zolpidem)
A 94-year-old residential aged-care resident died from drug toxicity after receiving another resident's medications. An agency nurse, unfamiliar with the patient and interrupted during medication preparation, failed to p…
69y · Female·Exacerbation of chronic obstructive pulmonary disease and ischaemic heart diseas…
Lynette McHarry, aged 69, died on 15 August 2024 at Casey Hospital following complications from a preventable medication error at Mooraleigh Hostel residential aged care facility. On 4 August, she was mistakenly administ…
78y · Female·medication error resulting in combined drug toxicity
Mrs LV, age 78, died at The Bays Aged Care facility on 2 January 2025 following a medication error four days earlier. An endorsed enrolled nurse (EEN), distracted by a phone call during her first shift, inadvertently adm…
72y · Male·Complications of suspected upper gastrointestinal tract haemorrhage, hospital ac…
A 72-year-old man with metastatic squamous cell lung cancer and multiple serious comorbidities was admitted to Ballarat Hospital in July 2024 with lethargy, fatigue, and rapid atrial fibrillation. Due to medication chart…
51y · Female·Chest sepsis in the setting of recurrent aspiration pneumonia, cerebral palsy, L…
Danielle Noonan, aged 51, died from chest sepsis secondary to recurrent aspiration pneumonia. She had severe disability including cerebral palsy, Lennox-Gastaut syndrome, spastic quadriplegia, and intellectual disability…
67y · Female·Pulmonary thrombo-embolism secondary to deep venous thrombosis, with contributin…
Vicki Grigg, 67, died from pulmonary embolism three days after discharge from Goulburn Valley Health. She had been admitted with influenza A exacerbating asthma and COPD, and received standard-dose anticoagulation prophy…
61y · Male·bronchopneumonia complicating cerebrovascular accident due to cardioembolism on …
A 61-year-old man with a mechanical aortic valve underwent colonoscopy requiring temporary warfarin cessation. Following the procedure, he was discharged with a plan to recommence warfarin but without clear postoperative…
70y · Male·Multiple organ failure secondary to bronchopneumonia and acute pancreatitis in a…
Philip Arnott, a 70-year-old man with schizophrenia, died from multiple organ failure secondary to bronchopneumonia and acute pancreatitis. He had taken the maximum recommended dose of paliperidone since 2015. Between Ja…
34y · Male·Hanging
BS, a 34-year-old man with PTSD and depression from previous custodial assault, was remanded on drug importation charges at MRRC during COVID-19 restrictions. Critical clinical failures included: (1) 118-day delay in psy…
61y · Male·Exsanguination from sharp force injuries to both arms, dissecting the veins of t…
CG, aged 61, died in Parklea Correctional Centre on 18 May 2024 from hemorrhage due to self-inflicted sharp force injuries. The coroner found multiple clinical and system failures contributed substantially to the death. …
72y · Female·Combined drug toxicity (tapentadol, fluoxetine)
Linda Joy Bridle, 72, died from combined drug toxicity (tapentadol and fluoxetine) with a contributing subdural haemorrhage. She had multiple chronic conditions including heart failure and chronic pain, managed through c…
17y · Male·Suicide by self-inflicted hanging
RL was a 17-year-old Alice Springs teenager who died by suicide while under Northern Territory mental health services' care. Critical clinical lessons emerged: failure to inform his mother about mental health deteriorati…
29y · Male·Cardiac arrhythmia in the context of alcohol withdrawal and chronic alcohol misu…
A 29-year-old man died from cardiac arrhythmia in the context of severe alcohol withdrawal at a correctional facility. Initial assessment correctly identified moderate-to-severe withdrawal (AWS score 8) with seizure hist…
Unknown·Nicholas Brown: combined drug (methadone and benzodiazepine) intoxication; Toni …
Joint inquest into four deaths of individuals prescribed opioid replacement therapy by Dr J. between September 2016 and August 2017: Nicholas Shane Brown (35), Toni Lee Wiki (38), Matthew Wayne Winwood (47), and Belinda …
85y · Male·systemic sepsis due to infected right perineal ulcer and associated perianal abs…
An 85-year-old man with dementia and multiple comorbidities died of sepsis caused by an infected sacral pressure ulcer that developed and deteriorated while resident at an aged care facility. Initially assessed as stage …
74y · Male·Acute myocardial infarction complicated by multiple organ failure
Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…
85y · Male·Sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left …
An 85-year-old man died in custody from sepsis due to Staphylococcus aureus bacteraemia arising from septic arthritis of the left shoulder, on a background of congestive heart failure. While receiving generally adequate …
25y · Male·Combined drug toxicity
Harrison William Ladd, 25, died from combined drug toxicity involving clonazepam, dexamphetamine, codeine, diazepam and pholcodine. He had complex mental health and substance use disorder requiring specialist addiction c…
31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)
A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …
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