69 results
36y · Female·Complications of pneumonia and pulmonary emphysema with bullae formation; respir…
A 36-year-old woman with congenital chest wall abnormality, scoliosis, and difficult intubation history presented to a rural hospital with community-acquired pneumonia and sepsis. She had multiple 'red flag' indicators o…
50y · Female·Hanging
Jacinta Dwyer, a newly appointed magistrate with limited criminal law experience, developed severe anxiety and depression within months of taking office in February 2017. Despite supportive interventions from senior judg…
48y · Female·Sepsis due to pulmonary and cutaneous infections, with urinary tract infection a…
A 48-year-old tetraplegic woman died from sepsis originating from a necrotic sacral pressure wound. Multiple system failures contributed: inadequate pressure sore prevention at the disability care provider (air mattress …
75y · Female·organ failure due to sepsis, likely from infected pressure sores, in the context…
Maria Carmel Niceforo, a 75-year-old woman with poorly controlled diabetes and ischaemic heart disease, died from septic shock secondary to extensive infected sacral pressure wounds. She received home care through KinCar…
63y · Male·blunt head and chest trauma from motor vehicle collision
Edmund Smordowski, a 63-year-old cyclist, was struck from behind by an 83-year-old driver, Kevin Rice, and died from blunt head and chest trauma. The collision occurred because Rice was unable to maintain his vehicle wit…
44y · Female·Combined drug toxicity (oxycodone, diazepam, and pregabalin)
Melissa May, a 44-year-old woman with chronic pain and opioid dependence, died from combined drug toxicity on 16 December 2013. She had been prescribed oxycodone, diazepam, and pregabalin by doctors at Rich River Health …
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…
6y · Male·pneumonia complicating influenza A (H1N1) infection with secondary streptococcal…
Sebastian Parman, a 6-year-old boy, died from pneumonia complicating influenza H1N1 with secondary group A streptococcal infection causing scarlet fever, empyema and sepsis. Multiple clinical failures contributed: an inf…
4y · Female·Haemorrhage due to aorto-oesophageal fistula caused by ingestion of a button bat…
A 4-year-old girl died from aorto-oesophageal fistula and haemorrhage caused by a lithium button battery lodged in her oesophagus for at least 3 days. Critical diagnostic failures occurred: the initial GP failed to consi…
31y · Female·Pneumonia; combined drug toxicity (including marijuana), smoking, pathological o…
Georgia Cheal, a 31-year-old with complex medical history including chronic pain, major depression, and obesity, died from pneumonia exacerbated by combined drug toxicity from multiple prescription medications, cannabis,…
76y · Female·Immersion (with underlying cause undetermined in circumstances of a fall into a …
76-year-old woman with vascular dementia and wandering behaviour was found submerged in a courtyard water fountain at an aged care facility after a fall. She remained unattended in a hazardous area for approximately 51 m…
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 …
79y · Female·pneumonia in the setting of acute peritonitis due to perforated stomach (operate…
Mrs Thelma Katherine Holt, a 79-year-old woman with multiple comorbidities including obesity, vascular disease, hypertension, and prior Nissen fundoplication, underwent placement of a second intragastric balloon on 11 Se…
Three deaths with different primary causes: James Unicomb - acute toxicity due t…
Combined inquest into three deaths at Psyche South Clinic involving treatment failures: James Unicomb (22, 2005) from multi-drug overdose after naltrexone implant; Michael Poole (48, 2008) from ruptured aneurysm post-Rap…
Toxicity from intravenous caesium, DMSO, and other substances administered as pa…
In May 2005, the Kathi Preston Memorial Health Centre (KPMHC) operated an unproven cancer therapy clinic from Dr. Alexandra Boyd's home in Perth, Western Australia, administering intravenous treatment containing caesium,…
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…
59y · Female·Subdural haemorrhage from blunt force trauma to head sustained in a backwards fa…
Lena Divola, a 59-year-old woman with intellectual disability, schizophrenia, and depression living in supported accommodation, sustained a head injury on 24 December 2007 when she fell backwards from a walker being push…
31y · Male·Overdose of quetiapine (Seroquel) in combination with alcohol
Travis Graham, a 31-year-old man with a history of mental illness, self-harm, and substance abuse, died from an overdose of quetiapine (Seroquel) combined with alcohol. He had previously overdosed on the same medication …
77y · Male·hypoxic-ischaemic encephalopathy and cerebral infarction due to upper airway obs…
A 77-year-old man with advanced dementia died from hypoxic-ischaemic encephalopathy caused by upper airway obstruction from a handkerchief. An agency carer placed a handkerchief in his breast pocket during morning care, …
1y · Female·pneumonia (staphylococcal pneumonia with bilateral bacterial pneumonia)
Jezelle Lisa Gordon, a 1-year-old child, died of staphylococcal pneumonia on 26 February 2006 in Port Hedland, Western Australia. She presented to Halls Creek Hospital on 25 February with fever, elevated respiratory rate…
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