326 results
32y · Male·plastic bag asphyxia
David Mathew Smith, 32, died by plastic bag asphyxia on 25 November 2007. He had schizophrenia, chronic motor tic disorder, sexual paraphilia, and a history of explosive-making offences. He was subject to concurrent bail…
29y · Female·Invasive aspergillosis
A 29-year-old registered nurse with systemic lupus erythematosus (SLE) died from invasive aspergillosis. Dr G. prescribed lamotrigine 100 mg daily (double the recommended initial dose of 50 mg) on first consultation with…
81y · Female·hypovolaemic shock following bleeding from the site of a femoral angiogram
Olga Krivitch, 81-year-old woman, died from hypovolaemic shock caused by bleeding from her femoral angiogram puncture site. She was admitted for ischaemic leg and underwent unsuccessful thrombolytic therapy. Subsequently…
39y · Female·Mixed drug toxicity (methadone, oxycodone, hydromorphone, mirtazapine, diazepam,…
A 39-year-old woman with chronic pain from a previous work injury died from mixed drug toxicity involving methadone, oxycodone, hydromorphone, diazepam, mirtazapine, and promethazine. Her pain specialist prescribed metha…
83y · Female·Congestive cardiac failure due to ischaemic and valvular heart disease
An 83-year-old woman with Down syndrome and cardiac disease died from congestive cardiac failure at Royal Adelaide Hospital following accidental medication administration error in a community group home. On 1 July 2007, …
82y · Female·Complications from hypoglycaemic brain damage and cerebral vascular accident
Margaret Allan Johnston, 82-year-old admitted for UTI and confusion, was found comatose on 4 September 2006 with severe hypoglycaemia (glucose 0.8 mmol/L) despite being non-diabetic. Blood tests revealed high insulin and…
65y · Male·acute right subdural haematoma
Sidney Brunt, aged 65, died from an acute right subdural haematoma caused by excessive, unmonitored anticoagulation with warfarin. His general practitioner, Dr A., prescribed warfarin for atrial fibrillation but failed t…
Female·Drowning (suicide)
Melissa Maree Blake died by suicide by drowning on 16 January 2007 while receiving community-based treatment for psychotic depression, which developed following a miscarriage. She was referred to Sunshine Coast Mental He…
62y · Female·Haemorrhage caused by abdominoperineal excision of the rectum
A 62-year-old woman died of uncontrollable haemorrhage following an abdominoperineal excision of the rectum (APER) at a remote hospital. The coroner found the operation itself was inappropriate: performed for undiagnosed…
36y · Male·morphine toxicity
A 36-year-old man with morbid obesity, possible sleep apnoea, and respiratory symptoms died from morphine toxicity after taking three 100mg MS Contin tablets within 6 hours, despite being opioid-naïve. He presented to ED…
45y · Male·choking on food
Richard Mann, a 45-year-old man with intellectual disability and psychiatric illness residing in an institutional setting (Strathmont Centre infirmary), died from choking on food. Critical failures in observation and mon…
54y · Female·sepsis
Ms Julie Stephens, aged 54, was admitted to Frankston Hospital on 5 December 2008 with a chest infection and multiple comorbidities including cardiac failure, respiratory failure, and obesity. She deteriorated with septi…
16y · Female·Respiratory arrest due to the depressant effect of opiate medication
Vanessa Anderson, 16, suffered a depressed skull fracture from a golf ball strike and was admitted to Royal North Shore Hospital. She died from respiratory arrest due to opioid-induced respiratory depression, which was e…
66y · Male·Coronary atherosclerosis
Frank Maurice Whittington, aged 66, died from coronary atherosclerosis on 24 February 2004, shortly after day surgery to replace a catheter on his intrathecal morphine pump. Dr R. and RN Couper administered a 0.26ml over…
37y · Male·acute heart failure caused by multiple drug toxicity (methadone and alprazolam)
Richard Mark Kiel, a 37-year-old with chronic opioid addiction, died from acute heart failure caused by lethally high levels of methadone and alprazolam, likely consumed on 9 September 2005. His GP, Dr G., prescribed the…
30y · Female·Multi-organ failure due to multiple transfusions required for post-operative ble…
Ms Cvitic, a 30-year-old woman with cervical cancer, underwent radical hysterectomy on 11 February 2002. She collapsed on 14 February with signs of hypovolaemic shock (haemoglobin 5.3 g/dL). Dr W. performed emergency lap…
40y · Male·respiratory failure due to Adult Respiratory Distress Syndrome (ARDS)
Michael Cockburn, a 40-year-old man with treatment-resistant schizophrenia and documented severe adverse reactions to antipsychotic medications, was admitted to Royal Adelaide Hospital from psychiatric detention for anae…
31y · Male·Undetermined; most likely coronary atherosclerosis leading to arrhythmia, but as…
Sparka Huntington, a 31-year-old forensic mental health patient with a history of schizophrenia, violence, and drug use, died during physical restraint by hospital security officers and nursing staff on 14 December 2003.…
Unknown·Erfinna Lay: Aspiration resulting from Acute Multiple Drug Toxicity; John Quirk:…
Two young people died from acute multiple drug toxicity in 2005. Erfinna Lay (22, female) died from aspiration after ingesting chloral hydrate prescribed to her partner. John Quirk (27, male) died from doloxene overdose …
26y · Male·bronchopneumonia following severe head injury
Ian Leslie West, a 26-year-old man with bipolar affective disorder, died from bronchopneumonia following severe head injury sustained when he fell from a hospital balcony on 31 December 2002. He had been admitted to Long…
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