91 results
72y · Male·The available evidence does not allow for any finding to be made as to the cause…
Bruce Robinson, a 72-year-old man with a history of non-Hodgkin's lymphoma, schizophrenia, psychosis, and dementia, died on 27 October 2022 after jumping from a ferry into Sydney Harbour. He had been non-compliant with h…
66y · Male·Cardiac arrhythmia in a man with arteriosclerotic cardiovascular disease, pulmon…
Bradley Stinson, a 66-year-old prisoner with a long history of heavy smoking and alcohol use, died from cardiac arrhythmia in the setting of arteriosclerotic cardiovascular disease, pulmonary thromboembolism, and metasta…
71y · Female·complications of metastatic endometrial carcinoma, treated palliatively
Corazon Contreras Keeley, a 71-year-old woman with postmenopausal bleeding, was investigated for possible endometrial cancer. Dr K. performed a hysteroscopy with dilation and curettage (HDC) on 29 November 2019, observin…
76y · Male·small bowel obstruction in the setting of terminal metastatic neuro-endocrine tu…
A 76-year-old Aboriginal man died of small bowel obstruction from metastatic neuro-endocrine tumour after spending nearly two years requesting medical help in prison without receiving a doctor's review. Between October 2…
73y · Male·Complications of metastatic neuroendocrine lung carcinoma
John O'Donnell, aged 73, died in custody from complications of metastatic neuroendocrine lung cancer while hospitalised at Westmead Hospital. The coroner identified two systemic issues during his brief incarceration at S…
76y · Male·Bronchopneumonia with multiple organ failure in the setting of advanced metastat…
John Henry Waterfall, a 76-year-old prisoner at Acacia Prison, died from bronchopneumonia with multiple organ failure secondary to advanced metastatic prostate cancer. He received generally appropriate medical care durin…
75y · Male·complications of metastatic prostate cancer and end-stage chronic obstructive pu…
Frank Kenneth Major, a 75-year-old prisoner with metastatic prostate cancer and end-stage COPD, died of natural causes in October 2021. The coroner found his overall medical care during incarceration was excellent and co…
76y · Female·Effects of fire in a woman with head and neck injuries
Mrs Emma Weidemann, aged 76, died from burns sustained in a fire deliberately set by her husband Rudolf at their home on 11 December 2019. Rudolf had recently been diagnosed with terminal cancer, experienced cognitive de…
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…
87y · Male·Metastatic carcinoma of the prostate with complications (end-of-life palliative …
Errol Warren Bartlett-Torr, aged 87, died of metastatic prostate cancer on 20 June 2021 whilst in prison custody and receiving palliative care at Bethesda Hospital. Clinical lessons include: (1) elevated PSA findings sho…
65y · Female·undetermined; possibly ischaemic heart disease or squamous cell carcinoma of ton…
A 65-year-old Malaysian woman with advanced squamous cell carcinoma of the tongue refused medical treatment due to visa concerns and preference for alternative therapy. She deteriorated over months with worsening oral sy…
84y · Male·Respiratory failure complicating hospital acquired pneumonia following surgical …
An 84-year-old man died from respiratory failure due to hospital-acquired pneumonia following surgery for recurrent mandibular squamous cell carcinoma. Key clinical lessons: (1) Advanced Care Plans (ACPs) must be activel…
80y · Female·Anaphylaxis complicating chemotherapy for the treatment of metastatic fallopian …
Ms Heather Jean Lucas, 80-year-old woman with metastatic fallopian tube cancer, died from anaphylaxis during her third carboplatin chemotherapy infusion. She had experienced a documented Grade 2 hypersensitivity reaction…
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…
76y · Male·Small bowel obstruction and acute renal failure, due to or as a consequence of m…
Adrian Adams, aged 76, died in Princess Alexandra Hospital from small bowel obstruction and acute renal failure secondary to metastatic colorectal cancer. He was serving an eight-year sentence for sexual offences at the …
71y · Male·Complications of metastatic squamous cell carcinoma (terminal palliation)
Leslie Shortte, a 71-year-old life prisoner, died from metastatic squamous cell carcinoma with complications. Critical failures in his prison medical care included: failure to complete annual health assessments after 201…
60y · Male·sepsis and aspiration pneumonia in a man with oral squamous cell carcinoma and m…
Henry Allen, a 60-year-old man with oral squamous cell carcinoma, lung cancer, and multiple comorbidities died from sepsis and aspiration pneumonia while in prison custody at Fiona Stanley Hospital. He received appropria…
57y · Male·Consequences of multiple injuries (from fall from elevated walkway)
Mladen Jovanoski, a 57-year-old remand prisoner, died from head injuries sustained after falling from a prison walkway on 11 April 2018. He had suspected metastatic thyroid cancer requiring urgent biopsy at a tertiary ho…
59y · Male·metastatic lung cancer, with palliation
Van Tho Nguyen, a 59-year-old remand prisoner with metastatic lung cancer, died of natural causes in a private hospital palliative care setting. He had been a lifelong smoker who developed advanced adenocarcinoma with bo…
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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