148 results
89y · Male·Complications in association with a gastrointestinal illness in an elderly man w…
Raymond Sydney Cheek, an 89-year-old prisoner with multiple comorbidities including insulin-dependent diabetes, died from complications of gastrointestinal illness with acute renal failure. While medical care at Casuarin…
87y · Male·Combined effects of sotalol toxicity on a background of severe valvular and athe…
An 87-year-old man with Alzheimer's disease died in a residential aged care facility after ingesting Sotalol, a cardiac medication not prescribed to him. The medication trolley was left unlocked and accessible despite fa…
70y · Female·Heart failure due to paroxysmal atrial fibrillation treated with flecainide card…
A 70-year-old woman with complex cardiac history including heart failure, paroxysmal atrial fibrillation, and coronary atherosclerosis presented with urinary tract infection and atrial fibrillation on Christmas Day 2021.…
81y · Male·Chronic lung disease (severe COPD) with atherosclerotic cardiovascular and valvu…
An 81-year-old man with severe COPD died following inappropriate interhospital transfer to a private hospital and subsequent management errors. Key clinical lessons: (1) patients with CO2 retention require explicit ident…
36y · Male·Undetermined; three possible mechanisms identified: oversedation with vomiting a…
Jacob Kennedy, a 36-year-old Aboriginal man with polysubstance use disorder and psychiatric illness, died on 4 February 2017 after 11 days as an involuntary inpatient at Frankston Hospital. He was administered multiple s…
16y · Male·mixed drug toxicity (codeine, morphine, tramadol, alprazolam and desmethylvenlaf…
LI, a 16-year-old with borderline personality disorder, factitious disorder, and opioid use disorder, died from mixed drug toxicity (codeine, morphine, tramadol, alprazolam, desmethylvenlafaxine) after obtaining prescrip…
2y · Male·multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndro…
A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poo…
61y · Male·congestive cardiac failure due to cardiomegaly with left ventricular hypertrophy
A 61-year-old man with diabetes, obesity, and high cholesterol presented to his GP with shortness of breath for 4-5 days and tachycardia (HR 120). The GP diagnosed anxiety instead of cardiac failure, failed to ask critic…
29y · Male·Methadone toxicity
Darren James Fielding died in custody at Middleton Prison on 26 May 2018 from methadone toxicity. He was on day 6 of opioid substitution therapy (OSTP) when he received his prescribed 10mg methadone dose. Expert evidence…
82y · Female·traumatic closed head injury (subdural haematoma) resulting from a fall from sta…
Mrs Emily Jones, 82, died from subdural haematoma following an unwitnessed fall at Royal Hobart Hospital on 15 November 2021. She was admitted five days after discharge from Hobart Private Hospital where she was treated …
73y · Male·Complications of metastatic neuroendocrine lung carcinoma
John O'Donnell, aged 73, died in custody from complications of metastatic neuroendocrine lung cancer while hospitalised at Westmead Hospital. The coroner identified two systemic issues during his brief incarceration at S…
32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome
Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included…
81y · Female·Subdural haemorrhage from fall with exacerbation by anticoagulant therapy
An 81-year-old woman with atrial fibrillation and Alzheimer's disease fell at home on 21 December 2020, sustaining a subdural haematoma. Nambour Hospital appropriately ceased her anticoagulant (rivaroxaban) and planned c…
46y · Male·Opioid toxicity (tapentadol and oxycodone)
Bradley Liefvoort, 46, died from opioid toxicity (tapentadol and oxycodone) at home in Dandenong. Over a decade of prescription medication misuse began with ibuprofen for headaches, escalating to opioid dependence follow…
34y · Female·Multi drug toxicity
Jodie Overstead, a 34-year-old with epilepsy, anxiety, and chronic pain, died from multi-drug toxicity involving tramadol, codeine, amitriptyline, benzodiazepines and other drugs. She engaged in 'doctor shopping', obtain…
91y · Male·Complications of cerebrovascular and ischaemic heart disease in a man post anaph…
A 91-year-old man with known diltiazem allergy was prescribed diltiazem by a geriatrician despite documented allergy records. The geriatrician relied on the patient's verbal denial of allergies despite significant dement…
79y · Female·medication related cardiac arrest (verapamil and propranolol) in a patient with …
Mrs Patricia Croxon, a 79-year-old admitted with community-acquired pneumonia, died from medication-related cardiac arrest caused by verapamil and propranolol. The verapamil was charted in immediate release form when she…
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
Maarouf El-Cheikh, a 57-year-old man with splenectomy history, presented to Calvary Hospital ED with sepsis on 21 March 2016 and died 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadeq…
70y · Male·Coronary atherosclerosis
Mirko Civic, a 70-year-old prisoner with a significant cardiac history including prior myocardial infarction, hypertension, and ischaemic heart disease, died of coronary atherosclerosis in September 2018. Critical clinic…
76y · Male·Chest sepsis in a man with ischaemic heart disease
A 76-year-old man with multiple myeloma and complex medical history died from chest sepsis and myocardial infarction following a medication dispensing error. After discharge from hospital for spinal compression fractures…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.