116 results
46y · Male·Opioid toxicity (tapentadol and oxycodone)
Bradley Liefvoort, 46, died from opioid toxicity (tapentadol and oxycodone) at home in Dandenong. Over a decade of prescription medication misuse began with ibuprofen for headaches, escalating to opioid dependence follow…
25y · Female·multiple injuries
A 25-year-old woman with newly diagnosed metastatic gastro-oesophageal cancer and depression died by suicide on hospital grounds. She was admitted on 30 January 2021 after imaging showed cancer progression. Her sister di…
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…
38y · Male·abdominal and chest sepsis complicating iatrogenic left pneumothorax and laparot…
A 38-year-old man with chromosome 1 short arm deletion syndrome, intellectual disability, and scoliosis died from sepsis following iatrogenic pneumothorax and emergency laparotomy for small bowel obstruction. He was admi…
89y · Male·Complications of cerebrovascular accident (stroke); specifically a catastrophic …
Hugh Ward, an 89-year-old sentenced prisoner, died from complications of stroke following an embolic cerebrovascular accident at Sir Charles Gairdner Hospital. While incarcerated, Mr Ward had multiple comorbidities inclu…
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…
71y · Female·Complications of cerebral palsy
Lorraine Earl, aged 71, died from complications of cerebral palsy at Wantirna Hospital following a palliative care pathway initiated after severe dysphagia developed during a hospital admission. The Disability Services C…
58y · Male·complications of large bowel pseudo-obstruction
Paul Desmond Smith, aged 58, died from complications of large bowel pseudo-obstruction following discharge from hospital after inadequate assessment. He had presented to the ED with lower abdominal pain and severe faecal…
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…
80y · Male·aspiration pneumonia
Ernest Charles Willetts, 80, died from aspiration pneumonia following an appendectomy. On hospital day 3, he developed coffee-ground vomitus indicating gastrointestinal bleeding. A gastroscopy was performed that afternoo…
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…
72y · Male·Diffuse large B cell lymphoma
Douglas Stott, a 72-year-old prisoner with diffuse large B cell lymphoma, died of natural causes in hospital on 7 January 2021. He had been receiving telehealth oncology consultations while incarcerated but refused in-pe…
17y · Male·Hypoxic ischaemic encephalopathy due to hanging
A 17-year-old male who transitioned from female died by hanging on 21 April 2020, seven days after discharge from psychiatric inpatient care. He had complex medical needs including chronic back pain, spinal fusion, post-…
70y · Male·bronchopneumonia in a man with intra-abdominal carcinoma and multiple co-morbidi…
Ronald Joseph Buckland, aged 70, died in custody at Fiona Stanley Hospital from bronchopneumonia with intra-abdominal carcinoma and multiple comorbidities. A life-sentenced prisoner, he had extensive medical conditions i…
75y · Female·Complications including acute pancreatitis and refractory intra-abdominal sepsis…
Lee Milcherdy, 75, died from complications including acute pancreatitis and refractory intra-abdominal sepsis following an unnecessary ERCP procedure. An MRCP scan on 12 October 2018 showed no gallstone, making the plann…
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 …
20y · Female·multi-organ failure due to polypharmacy overdose
A 20-year-old woman with depression and borderline personality disorder died from multi-organ failure following a large polypharmacy overdose (13 grams of paracetamol among 78 tablets). She was admitted to the ED where i…
31y · Male·Complications in association with intestinal volvulus
31-year-old Morgan Edwards with Smith-Magenis Syndrome, cerebral palsy and Crohn's disease was discharged from Fiona Stanley Hospital ED on 14 August 2018 without definitive diagnosis despite elevated respiration rate, u…
17y · Unknown·hypoxic brain damage from out of hospital cardiac arrest
FL was a 17-year-old with complex medical needs including short bowel syndrome and dependence on total parenteral nutrition (TPN) via central vascular access device. In June 2020, he became severely unwell with deteriora…
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 …
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