39 results
86y · Female·aspiration pneumonia
Viola Diana Clarke, an 86-year-old woman with multiple comorbidities including congestive heart failure, COPD, renal failure, gastric reflux and dysphagia, died from aspiration pneumonia. She was administered incorrect m…
87y · Female·combined effects of ischaemic heart disease and chronic obstructive pulmonary di…
Epenesa Pahiva, 87-year-old resident with dementia at an aged care facility, suffered severe chemical burns from inappropriate bleach treatment prescribed by dermatologist Dr B.. The coroner found the treatment itself (h…
83y · Female·Pneumonia complicating rib and pelvic fractures sustained in the setting of mult…
Margaret Barton, 83, died of pneumonia complicating rib and pelvic fractures from multiple falls. Critical clinical lessons: (1) The Oxazepam regimen directly contributed to her death. Dr C. tripled her dose from 15mg to…
55y · Male·Cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and…
Nigel Douglas Roberts, a 55-year-old man with chronic schizophrenia, COPD, and cardiomyopathy, died from cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and olanzapine) in the presence of adv…
64y · Male·Septic shock secondary to urosepsis (Pseudomonas and Stenotropomonas maltophilia…
RD, a 64-year-old man with diabetes, amputation, and COPD, presented to a private hospital emergency department with suspected sepsis (vomiting, diarrhoea, hypotension, acute kidney injury, elevated troponin, hyperkalaem…
86y · Male·Sepsis with septic shock, due to urinary tract infection, pyelonephritis (kidney…
An 86-year-old man died from sepsis and septic shock secondary to urinary tract infection, pyelonephritis and prostatic infection. He presented to his GP in March 2015 with dizziness and reported urinary incontinence and…
75y · Female·hypovolaemic shock following uncontrolled blood loss from mini-liposuction stem …
A 75-year-old woman with advanced frontal lobe dementia died from hypovolaemic shock following uncontrolled bleeding after an unproven stem-cell liposuction procedure. Critical failures included: failure to cease anticoa…
78y · Male·Cerebral infarction and hypoxic brain damage due to the combined effects of isch…
Paul Henri, 78, died from cerebral infarction and hypoxic brain damage following aspiration pneumonia and opioid-related complications. He was admitted to an aged care home and commenced on MS Contin (morphine) 30mg dail…
70y · Female·Aspiration pneumonia, associated with Huntington's disease
Beryl Watson, a severely disabled 70-year-old with advanced Huntington's disease and dementia, died of aspiration pneumonia following a three-week respite stay at a BUPA aged care facility. Critical failures included: om…
92y · Female·Ischaemic heart disease in the setting of inappropriate administration of antihy…
Norma Bensley, a 92-year-old aged care resident, died from ischaemic heart disease after being inadvertently administered another resident's antihypertensive medications. A newly qualified nurse administered the wrong me…
84y · Female·Major cerebral infarct due to hypoglycaemia
Marie Goder, an 84-year-old with diabetes, developed severe hypoglycaemia following insulin administration at a nursing home on 1 November 2009, resulting in prolonged unconsciousness and bilateral cerebral infarcts. Aft…
76y · Female·colchicine toxicity
A 76-year-old woman with gout died from colchicine toxicity after being prescribed 500µg three times daily on 9 December 2010 for an acute attack. She developed diarrhoea from 15 December and died on 19 December with a p…
87y · Female·heart failure and probable pneumonia in an elderly lady complicated by morphine …
An 87-year-old woman with dementia, heart disease, and hypertension presented with chest pain and hypoxia. A locum doctor (Dr B.) administered 20mg morphine intramuscularly without reviewing the patient's notes, medical …
Unknown·Multiple: Olanzapine toxicity, pulmonary thromboembolism, asphyxiation on food, …
This inquest examined six sudden deaths of residents at 300 Hostel, Marrickville, between June 2009 and August 2010. All residents had schizophrenia on multiple antipsychotic medications and severe, untreated physical co…
63y · Male·cerebral infarction
John Arthur Burns, a 63-year-old man with frontotemporal dementia and motor neurone disease, died from cerebral infarction on 17 September 2006 while in Westminster Aged Care Facility after only 12 days of residence. Des…
28y · Female·bronchopneumonia complicating oxycodone toxicity
Melissa Jay Tatchell, aged 28 with severe anorexia nervosa (BMI 11.8, weight 29kg), died from bronchopneumonia complicating oxycodone toxicity. A locum doctor with no prior experience with oxycodone prescribed inappropri…
86y · Female·Unable to be determined
An 86-year-old woman resident in aged care died with toxicology revealing a potentially fatal concentration of sertraline (1.7mg/kg, with metabolite at 2.3mg/kg; fatal range 0.61–1.6mg/kg). A clinical pharmacologist opin…
81y · Male·bronchopneumonia
An 81-year-old man with dementia, congestive cardiac failure, chronic lung disease and hip fractures died of bronchopneumonia four days after discharge from palliative care to a nursing home. While an administrative erro…
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…
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