26 results
56y · Male·complications of viral hepatitis related advanced-chronic liver disease
Russell Graham Penny, 56, a Noongar man, died from advanced liver disease with hepatocellular carcinoma while in prison custody. With chronic hepatitis C from intravenous drug use, Russell had developed cirrhosis and was…
26y · Male·Multi-organ failure due to pneumococcal septic shock
A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…
30y · Female·Acute ethanol toxicity on a background of chronic alcoholism
Kathleen Arnold, aged 30, died from acute ethanol toxicity on a background of chronic alcoholism. She had a 20-year history of alcohol dependence, complex trauma from a childhood near-drowning incident, eating disorders,…
55y · Male·Complications of liver cirrhosis and hepatocellular carcinoma in a man with mult…
Robert Exell, a 55-year-old Aboriginal man, died from complications of liver cirrhosis and hepatocellular carcinoma while in custody. He had chronic hepatitis C and alcohol-related liver disease since at least 2012. Key …
66y · Male·Complications of metastatic lung adenocarcinoma, with terminal palliative care, …
Karl Frederick Dominic Holmes, a 66-year-old prisoner with metastatic lung adenocarcinoma and hepatocellular carcinoma, died from complications of his terminal cancer while serving a 7-year sentence. He received excellen…
33y · Male·Haemoperitoneum secondary to lacerated spleen as a result of peritoneal ascitic …
A 33-year-old man with severe alcoholic liver disease (Child-Pugh C) and poor prognosis died from haemoperitoneum following splenic laceration during a diagnostic ascitic tap procedure. Two junior doctors (HMOs/Basic Phy…
64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …
Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart fai…
45y · Male·Intra-abdominal haemorrhage due to ruptured spleen due to splenomegaly due to ci…
Hayward Rasmussen, a 45-year-old man with cirrhosis and severe splenomegaly, died from intra-abdominal haemorrhage due to ruptured spleen while in custody. He collapsed in prison after sustaining possible rib injuries fr…
59y · Male·complications of viral liver cirrhosis with hepatocellular carcinoma
Mervyn Morgan, aged 59, died from complications of hepatocellular carcinoma arising from cirrhosis while in prison custody. Critical failures included: delayed monitoring of known liver cirrhosis (no ultrasound despite M…
51y · Female·Multiple injuries sustained from a fall from the top floor of a multi-storey car…
Justine Painter, aged 51, died from multiple injuries sustained jumping from a multi-storey carpark while an inpatient at Royal Perth Hospital (RPH). She had severe treatment-resistant schizoaffective disorder, command h…
62y · Female·Hypovolaemic and cardiogenic shock (hysterectomy) in the context of cardiomegaly…
A 62-year-old woman with significant comorbidities (cirrhosis, cardiomegaly, thrombocytopenia, chronic kidney disease, COPD) died from hypovolaemic and cardiogenic shock during elective total laparoscopic hysterectomy fo…
47y · Female·Traumatic closed head injury likely sustained in a fall from standing
TS, a 47-year-old woman with a 18-year history of anorexia nervosa, bulimia, and severe alcoholism, died from a traumatic closed head injury sustained in a fall from standing. At autopsy, blood alcohol concentration was …
52y · Male·complications in association with advanced malignancy (hepatocellular carcinoma)…
Jeffrey Lee Strettles, a 52-year-old prisoner, died from complications of advanced hepatocellular carcinoma, end-stage cirrhosis, and generalised sepsis. He had contracted Hepatitis C in the late 1980s and was diagnosed …
62y · Male·metastatic hepatocellular carcinoma
Michael Anthony Curran, a 62-year-old prisoner, died from metastatic hepatocellular carcinoma in 2015. He had been diagnosed with hepatitis C in 2005, which is a significant risk factor for liver cancer. A liver biopsy i…
Male·Complications of alcohol and hepatitis C-related liver disease
Peter Young, an Aboriginal man with advanced alcoholic cirrhosis and recently acquired hepatitis C infection, died of multi-organ failure while on remand in custody. He received appropriate standard medical care in priso…
67y · Female·bronchopneumonia and acute liver failure on a background of liver cirrhosis and …
Valerie Kelly, a 67-year-old woman with cirrhosis, hepatocellular carcinoma, and multiple comorbidities, died at Royal Perth Hospital from bronchopneumonia and acute liver failure. She was in custody at Bandyup Women's P…
41y · Male·Fulminant sepsis (Klebsiella pneumoniae) with multi-organ failure complicating s…
A 41-year-old man with newly diagnosed severe Crohn's colitis was prescribed 6-mercaptopurine (6-MP) after only 5 days of hospital treatment. He had a homozygous TPMT gene deficiency (present in ~0.3% of population) that…
55y · Male·gastrointestinal haemorrhage due to oesophageal varices due to hepatocellular ca…
Robert McIntosh, a 55-year-old prisoner with undiagnosed cirrhosis of the liver, hepatitis C, and hepatocellular carcinoma, died from gastrointestinal haemorrhage and oesophageal varices. While the coroner found that med…
53y · Male·decompensated alcoholic liver disease in the setting of gastro-intestinal haemor…
A 53-year-old man with advanced alcoholic liver disease (Child-Pugh C) died of decompensated liver disease with gastrointestinal haemorrhage. He was arrested for drunk in public place, lodged in police cells, and release…
33y · Female·multiple organ failure complicating sepsis in a woman with cirrhosis of the live…
Amy Tinker, a 33-year-old Aboriginal woman with unrecognised cirrhosis from chronic alcohol abuse, died from sepsis-related multi-organ failure while imprisoned. She had been admitted to Royal Perth Hospital in 2004 with…
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