259 results
73y · Female·Bacterial endocarditis organism arising from a staphylococcal infection that ent…
Mary Roberts, aged 73, received a 5-year custodial sentence in September 2004. She had complex medical needs: dementia from previous strokes, diabetes requiring insulin monitoring, and Warfarin use. Justice Health provid…
64y · Male·Large pulmonary embolus (origin undetermined)
Paul Brauer, 64, died of pulmonary embolus at Leeton District Hospital following a complex admission involving psychiatric depression, atrial fibrillation, urinary retention, and multiple comorbidities. The coroner ident…
26y · Female·Streptococcal Sepsis resulting from Skin Ulceration and complications of Cerebra…
Kate Therese Bugmy, a 26-year-old woman with cerebral palsy, epilepsy, and intellectual disability, died on 28 June 2007 of Streptococcal sepsis from infected pressure ulcers. She was cared for at home by her mother Daph…
73y · Female·neck compression by ligature
Sofija Dobrijevic, a 73-year-old woman detained under the Mental Health Act, died by ligature strangulation in a closed psychiatric ward at Glenside Hospital. She had chronic pain since a 2002 fall, depression, and histr…
64y · Female·Haemorrhage into atheromatous plaque, due to coronary atherosclerosis
Fay Cramb, a 64-year-old woman imprisoned for 20+ years, died on 27 May 2008 from coronary atherosclerosis with haemorrhage into atheromatous plaque. She suffered an acute cardiac event on 5 May 2008 requiring emergency …
54y · Male·Pneumonia
Peter Bannan, age 54, had lifelong quadriplegia and intellectual disability from early childhood encephalitis, with chronic epilepsy and severe aspiration risk. He was admitted on 5 October 2007 with aspiration pneumonia…
32y · Female·Mexiletine toxicity
Janet Rosse was a 32-year-old woman with hyperkalaemic periodic paralysis, a genetic neurological condition causing recurring paralytic episodes and chronic pain, and a concurrent history of major depression and anxiety.…
8y · Male·Hypoxic Ischaemic Encephalopathy resulting from asphyxiation due to co-sleeping …
Nathaniel West, an 8-day-old Aboriginal newborn, died from hypoxic ischaemic encephalopathy following accidental asphyxiation due to co-sleeping (bed-sharing) with his mother at Kalgoorlie Regional Hospital on 4 May 2006…
62y · Female·gastric necrosis and perforation due to strangulated diaphragmatic hernia
Joyce Wilman, 62, died from gastric necrosis and perforation due to strangulated para-oesophageal hernia whilst detained under Mental Health Act at Queen Elizabeth Hospital. She presented with vomiting and abdominal pain…
64y · Male·hospital-acquired pneumonia on a background of end-stage cryptogenic liver cirrh…
Peter Langford, aged 64, died of hospital-acquired pneumonia complicated by end-stage cryptogenic liver cirrhosis after a 43-day admission to Flinders Medical Centre. He presented with severe cellulitis requiring amputat…
88y · Female·pneumonia and morphine toxicity in an elderly lady with a recent left leg and le…
Pauline Margaret Partington, an 88-year-old woman, suffered an unwitnessed fall at a residential aged care facility on 4 May 2008 and sustained a fractured left neck of femur, displaced fracture of the left humerus, and …
45y · Female·aspiration of vomitus with bowel obstruction due to faecal impaction
Vicki Margaret Greeuw, a 45-year-old woman with schizoaffective disorder, died on 13 May 2007 at Albany Regional Hospital from aspiration of vomitus secondary to bowel obstruction due to severe faecal impaction. She had …
60y · Male·Hypertensive heart disease with chronic fatty liver as other significant conditi…
David Duggan, a 60-year-old man with hypertensive heart disease and cardiomegaly, was admitted to Caloundra Hospital on 10 January 2007 for management of severe acute back pain caused by a suspected L3/4 disc herniation …
65y · Male·acute right subdural haematoma
Sidney Brunt, aged 65, died from an acute right subdural haematoma caused by excessive, unmonitored anticoagulation with warfarin. His general practitioner, Dr A., prescribed warfarin for atrial fibrillation but failed t…
62y · Male·Acute Gastrointestinal Haemorrhage in association with Acute on Chronic Peptic U…
Kenneth Charles Fox, 62, presented to Fremantle Hospital ED on 12 April 2006 with a gastrointestinal bleed after fainting. He was diagnosed with a massive bleed causing hypovolaemic shock and stabilized with fluid resusc…
47y · Female·Cardiac arrhythmia due to severe coronary artery atherosclerosis
A 47-year-old woman presented to a level one rural hospital with chest pain. The doctor diagnosed muscular pain (99% certain) and discharged her without troponin testing or admission, despite chest pain being the present…
64y · Female·acute subdural haemorrhage sustained after a fall on Ward 4A
Margaret Winter, 64, died from acute subdural haemorrhage following a fall on Ward 4A on 13 December 2006. She had been admitted with decompensated liver disease. Her falls risk was misclassified as low when it should ha…
76y · Male·ruptured abdominal aortic aneurysm
Kenneth Carter, 76, died from a ruptured abdominal aortic aneurysm (AAA) on 8 June 2005. He had presented to Flinders Medical Centre Emergency Department on 1 June 2005 with back pain, hypotension (90/65 mmHg), and two e…
41y · Male·Head Injury in a Man with Acute Alcohol Intoxication; basal skull fracture with …
Ronald Gregory Kidner, 41, died from a basal skull fracture and severe head trauma on 25 October 2004, four days after falling at a recreation club while acutely intoxicated. He presented to Nickol Bay Hospital with sign…
29y · Male·aspiration pneumonia complicating acute and chronic Wernicke's encephalopathy an…
Grant Austin, a 29-year-old man with intellectual disability and morbid obesity, died from aspiration pneumonia complicating Wernicke's encephalopathy. He presented with prolonged refusal to eat and drink from December 2…
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