157 results
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…
84y · Female·Complications associated with Diabetes Mellitus (likely hyperosmolar hyperglycae…
Mrs Charlotte Paluszak, 84, died at a residential aged care facility after rapid deterioration from complex dementia and diabetes. On 10 November 2017, she developed acute semiconsciousness and agitation. The clinical nu…
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.…
65y · Male·Cardiac arrhythmia, probably Torsades de Pointes, due to the combined effects of…
Linus Phillips, age 65, died at home in October 2014 from cardiac arrhythmia (Torsades de Pointes) precipitated by methadone prescribed with inadequate oversight. Mr Phillips had chronic pain from knee surgery, severe sl…
David Edwards: disseminated lymphomatosis complicating large B-cell lymphoma. Ne…
David Edwards, aged 90, died of disseminated lymphomatosis (advanced lymphoma) on 2 March 2016. His death was natural and expected given his terminal illness. His wife Nelda Edwards, aged 88, died two days later on 4 Mar…
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…
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…
36y · Female·Stab wound to the right chest
Amanda Jane Harris, 36, was fatally stabbed by her intimate partner Daniel Eckersley on 7 July 2018 in Cranbourne North, Victoria. Eckersley was prescribed high-dose tramadol (700-800mg daily) for chronic pain over 22 mo…
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…
64y · Male·Complications of eosinophilic asthma with bronchiectasis and allergic bronchopul…
Wayne Mullin, a 64-year-old man with severe eosinophilic asthma, bronchiectasis, and allergic bronchopulmonary aspergillosis, died between 21 September and 20 October 2021. Toxicology revealed oxycodone and diazepam at l…
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…
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…
87y · Female·Complications following a medication administration error in a woman with multip…
An 87-year-old woman died from complications of a medication administration error at an aged care facility. During transition from paper-based to electronic medication charts in December 2020, a pharmacy data entry error…
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…
47y · Female·Mixed drug toxicity (pregabalin, oxycodone and mirtazapine)
A 47-year-old woman died from mixed drug toxicity involving pregabalin, oxycodone, and mirtazapine. She had chronic pain, anxiety, and depression, and attended a medical clinic frequently. Over five days before her death…
51y · Female·Mixed drug toxicity
A 51-year-old woman with longstanding treatment-resistant depression, chronic pain, and suicidal ideation died from mixed drug toxicity. She intentionally overdosed on multiple medications including benzodiazepines, anti…
71y · Female·ischaemic cardiovascular disease
Diane Eastcott, a 71-year-old involuntary mental health patient, died of ischaemic cardiovascular disease on 10 July 2018 at Macquarie Hospital. Following an unwitnessed fall on 22 June 2018, she was admitted to Ryde Hos…
38 and 3y · Female and male·Stacey: hanging; Seth: undetermined causes (likely suffocation, drowning, or str…
Stacey Docherty, a 38-year-old woman with complex post-traumatic stress disorder and borderline personality disorder resulting from childhood sexual abuse, killed her 3-year-old son Seth before taking her own life in Mar…
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