48 results
Unknown·Choking; Mr Gesios: large bolus of bread and scrambled eggs causing complete air…
Two aged care residents died from choking on bread despite being prescribed minced and moist diets that prohibited regular bread. Mr Gesios was fed bread dipped in Milo by an inexperienced AIN without adequate supervisio…
39y · Male·Mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) with contribut…
Kevin Thomas Maloney, a 39-year-old man with complex mental health conditions and substance use disorder, died from mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) while residing in a supported resident…
89y · Female·Acute upper airway obstruction by food bolus
An 89-year-old woman with dementia died from acute upper airway obstruction by food bolus while being fed lunch at an aged care facility. CCTV footage revealed significant discrepancies between reported actions and actua…
Unknown·COVID-19 infection with various comorbidities as contributing factors
This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…
79y · Female·Chronic obstructive pulmonary disease
Jean Alice Dowson, 79, died in an aged care facility after being commenced on end-of-life medications. She had severe COPD and was frail (29kg). On 10 April 2017, when she deteriorated with respiratory distress, a Clinic…
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…
64y · Male·hypoxic-ischaemic encephalopathy and its complications following cardiac arrest …
Christopher Lens, a 64-year-old man with schizophrenia under guardianship at a nursing home, died from hypoxic-ischaemic encephalopathy following cardiac arrest due to upper airway obstruction after choking on a peanut b…
80y · Female·multiple injuries in the setting of a fall
Catherine Mary Reid, aged 80, died from multiple fractures sustained in a fall during a mechanical hoist transfer at a disability care facility. While being transferred from wheelchair to bed using an overhead ceiling ho…
74y · Female·Fractures of the legs, with terminal palliative care, in an elderly lady with mu…
Ms Papanastasiou, a 74-year-old aged care resident confined to a wheelchair, died from bilateral femoral fractures sustained when she fell from her wheelchair during sudden bus braking. The wheelchair was secured using o…
66y · Male·unascertained (differential diagnosis: chronic alcoholism with alcohol withdrawa…
Colin Norman, a 66-year-old man with significant disability from traumatic brain injury, chronic alcoholism and liver cirrhosis, died at home after failing to receive essential disability support services over a weekend.…
84y · Female·pneumonia and fracture of the neck of right femur following a fall
Mrs Bell, aged 84, died from pneumonia and a fractured right femoral neck sustained in a fall at a residential aged care facility. She had advanced Alzheimer's disease, cognitive impairment, impulsive behaviour, and was …
92y · Male·left haemothorax and rib fractures resulting from a fall at a residential aged c…
A 92-year-old man with multiple comorbidities (cardiac failure, COPD, chronic renal failure, diabetes) and documented high falls risk sustained a fall at a residential aged care facility on 12 May 2021, resulting in left…
82y · Male·hypostatic pneumonia
An 82-year-old man with dementia and multiple comorbidities died of hypostatic pneumonia following complications from a fall at a residential aged care facility. He sustained an L2 compression fracture from an unwitnesse…
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…
90y · Female·Multiple rib and pelvic fractures due to a fall from a wheelchair on sloping lan…
Cynthia Stevens, aged 90, died from multiple fractures sustained when her wheelchair rolled uncontrolled down a steep slope in a medical car park. The primary clinical lessons include: (1) inadequate application of wheel…
66y · Male·sepsis following bacteraemia caused by transurethral catheter insertion
A 66-year-old man with severe dementia and multiple comorbidities died from sepsis following bacteraemia after a routine indwelling urinary catheter change at a nursing home. The catheter insertion was traumatic, resulti…
44y · Female·Complications of a lung abscess with contributing factors of Down's syndrome and…
Melissa Cunningham, a 44-year-old woman with Down's syndrome and severe obesity, died from complications of a lung abscess. She required a CPAP machine for sleep apnoea, prescribed and monitored by Western Health since 2…
88y · Female·Head injury in a fall due to atrial fibrillation on anti-coagulants
An 88-year-old woman with atrial fibrillation on anticoagulation died from a subdural haemorrhage sustained in a fall at a rehabilitation hospital. She was assisted to the toilet by a single nursing student despite a doc…
87y · Female·closed traumatic head injury from a fall at standing height; significant contrib…
An 87-year-old woman with dementia, congestive cardiac failure, and diabetes sustained a fatal closed head injury from a fall in her aged care room overnight. The coroner found that the responsible ECA did not perform th…
78y · Female·cardiorespiratory failure, ischaemic and hypertensive heart disease together wit…
Barbara Francis, a 78-year-old resident with dementia at Pearl Supported Care in the dementia unit (Dinah), was punched by another resident (Mr A) on 4 September 2018 and fell backward onto her right hip, sustaining an o…
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