157 results
68y · Male·Cardiac arrest - unascertained etiology with multiple contributing factors inclu…
Wayne Thomas Kerle, 68, was arrested at his home for cannabis possession. Queensland Ambulance Service paramedics assessed him when he reported respiratory distress but cleared him for police custody after a limited exam…
87y · Female·Oesophageal perforation following an elective oesophageal dilatation, secondary …
87-year-old Helen Mahlis died from oesophageal perforation following an elective balloon dilation procedure at Epworth Richmond for treatment of achalasia. The coroner identified two contributing factors: use of a 35mm b…
29y · Male·Cardiac arrhythmia in the context of alcohol withdrawal and chronic alcohol misu…
A 29-year-old man died from cardiac arrhythmia in the context of severe alcohol withdrawal at a correctional facility. Initial assessment correctly identified moderate-to-severe withdrawal (AWS score 8) with seizure hist…
0y · Male·Perinatal hypoxia
Baby R, born at 39 weeks 6 days via planned homebirth with private midwives, died from perinatal hypoxia on day 6 of life. The mother had significant obstetric risk factors: previous emergency caesarean section, macrosom…
86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall
James Reilly, 86, fell at home on 8 September 2024 sustaining rib fractures that caused a fatal left haemothorax. Paramedics attended but he declined transfer. When facial droop developed, he was admitted with presumed t…
60y · Male·Pulmonary tuberculosis in a man with chronic obstructive pulmonary disease, with…
David John Hatcher, aged 60, was a remand prisoner at Hakea who died at Fiona Stanley Hospital on 27 September 2024 from pulmonary tuberculosis superimposed on severe chronic obstructive pulmonary disease. He was hospita…
49y · Female·Hypoxia due to complications following incision and drainage of a right buttock …
A 48-year-old woman with multiple comorbidities (diabetes, COPD, chronic kidney disease, ischaemic heart disease) died following complications of anaesthesia during incision and drainage of a buttock abscess. Critical fa…
16y · Male·complications of ligature compression of the neck (hanging)
A 16-year-old Aboriginal youth, Cleveland Keith Dodd, died by suicide via hanging in Unit 18, a youth detention centre housed within an adult maximum-security prison in Western Australia. The coroner found Cleveland's de…
83y · Male·Sepsis due to staphylococcus aureus bacteraemia following infection of a left an…
An 83-year-old man with heart and kidney failure died from sepsis caused by MSSA bacteraemia following infection at a peripheral intravenous catheter (PIVC) insertion site. Ambulance paramedics inserted the PIVC 56 hours…
73y · Male·Complications of cervical fractures and spinal injury (operated), sustained in a…
A 73-year-old man with multiple comorbidities (diabetes, cardiac disease, liver cancer) slipped on wet tiles outside McDonald's and sustained cervical and thoracic spine fractures with spinal cord injury. Attending param…
76y · Female·multi-organ failure and sepsis due to complications of cholecystectomy
A 76-year-old woman died from multi-organ failure and sepsis following a laparoscopic cholecystectomy at a rural hospital. During surgery, the surgeon became misoriented in the inflamed surgical field and divided the com…
42y · Male·Multiple organ failure due to iatrogenic phenol overdose due to metastatic pancr…
A 42-year-old man with metastatic pancreatic cancer died from multiple organ failure caused by iatrogenic phenol overdose during a celiac plexus block for pain management. The radiologist administered 40ml of 80% phenol …
67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…
Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pa…
62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…
A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…
5y · Male·Complications of burns
A 5-year-old boy died from complications of severe burns sustained during a fuel ignition incident at his father's rural property. While refuelling a small motorcycle, the father failed to shut off the engine and did not…
47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…
Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…
17y · Male·Gunshot wound to the head
Dustin Buckley, 17, died from a gunshot wound to the head at Royal Melbourne Hospital on 27 August 2017. The incident occurred during target shooting at Cat Track when KD fired a .22 rifle that discharged, striking Dusti…
40y · Male·Acute hepatic and renal failure in the setting of postoperative haemorrhage foll…
A 40-year-old man with obesity, COPD, diabetes and hypertension died from acute hepatic and renal failure following postoperative haemorrhage after left radical nephrectomy for a 10cm renal cell carcinoma. The surgeon ap…
74y · Female·Post-operative exacerbation of delirium and terminal functional deterioration du…
Jane Ann Chapman, 74, presented to hospital with delirium, fever and suspected urinary tract infection. She fell from an Emergency Department trolley bed, sustaining a neck of femur fracture requiring surgery. Post-opera…
0y · Male·Hypoxic-ischemic encephalopathy and massive subgaleal haemorrhage, both associat…
Baby X, born at Canberra Hospital after a prolonged labour, died at age 2 days from injuries sustained during birth. Two interlinked pathologies contributed to death: hypoxic-ischemic encephalopathy (HIE) from prolonged …
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