406 results
41y · Female·Cardiomegaly
Jessica Katgert, aged 41, died in custody at Dame Phyllis Frost Centre from cardiomegaly. She had a history of MSSA infective endocarditis treated in 2021 with echocardiographic changes including dilated left ventricle a…
69y · Male·thoracic aortic aneurysm with dissection
Peter Hanisch, a 69-year-old man, died from thoracic aortic aneurysm with dissection on 22 August 2021. He presented to Calvary Hospital on 19 August 2021 with sudden chest discomfort and neurological symptoms. A CT angi…
67y · Male·Intracranial haemorrhage complicating coronary artery bypass graft surgery follo…
A 67-year-old man died from intracranial haemorrhage following coronary artery bypass graft surgery. He had suffered a right coronary artery dissection during percutaneous coronary intervention at Sunshine Hospital and w…
62y · Male·cardiac arrhythmia secondary to prolongation of the QT interval
NL, a 62-year-old man with schizoaffective disorder and hypothyroidism, died of cardiac arrhythmia secondary to QT prolongation while an involuntary mental health inpatient. He had a known history of non-compliance with …
45y · Male·atherosclerotic heart disease
Lex Gregory Maher, a 45-year-old Aboriginal man imprisoned at Greenough Regional Prison, died of atherosclerotic heart disease while playing basketball. He had abnormal ECGs detected in March and May 2022 and was appropr…
90y · Male·Pneumonia complicating injuries sustained in a motor vehicle incident
A 90-year-old man died from pneumonia following injuries sustained in a motor vehicle collision. He had multiple reportable medical conditions including atrial fibrillation, coronary artery disease, chronic kidney diseas…
43y · Male·Complications of valvular heart disease
Michael James Batten, a 43-year-old with intellectual disability and schizophrenia, died from complications of aortic valve stenosis. A transoesophageal echocardiogram in June 2022 demonstrated severe aortic stenosis req…
75y · Female·multiple organ failure due to severe anaemia secondary to blood loss post electi…
A 75-year-old woman died from multiple organ failure due to severe anaemia after elective hysterectomy surgery. Critical failures occurred: the surgical and anaesthetic teams held conflicting understandings about whether…
73y · Male·Complications of multiple injuries sustained in a motor vehicle incident (car vs…
A 73-year-old man with extensive medical comorbidities including severe biventricular heart failure, COPD, sleep apnoea, and hypertension experienced a medical episode while driving, causing him to cross into oncoming tr…
82y · Male·Ischaemic heart disease due to coronary atherosclerosis with significant contrib…
An 82-year-old man with advanced ischaemic heart disease and emphysema died from myocardial infarction while in custody in the Acute Care Management Unit of a correctional facility. Correctional officers failed to read h…
66y · Male·infectious complications of plasmablastic myeloma
Mati Tamwoy, a 66-year-old Aboriginal man, died in ICU from infectious complications of plasmablastic myeloma after 661 days on remand. He received excellent oncological care including chemotherapy and radiotherapy. Howe…
68y · Female·Acute myocardial infarction and coronary artery atherosclerosis
A 68-year-old woman presented to St Vincent's Hospital emergency department with upper abdominal and left-sided chest pain following a stationary bicycle fall. Clinicians attributed her symptoms to codeine adverse reacti…
81y · Female·Multisystem failure in the setting of hyponatraemia secondary to chronic malnutr…
An 81-year-old woman with chronic schizophrenia, heart failure, and dementia died from multisystem failure secondary to severe malnutrition and hyponatraemia. Over four years, her son (Medical Power of Attorney) progress…
53y · Male·ischaemic heart disease in the setting of acute on chronic alcohol ingestion
A 53-year-old man with chronic heavy alcohol consumption and undiagnosed ischaemic heart disease died from acute alcohol intoxication superimposed on coronary artery atherosclerosis. Post-mortem blood alcohol was 0.36g/1…
41y · Male·Cardiomegaly in a man with WHO Class III obesity
Michael Suckling, a 41-year-old Aboriginal man, died in prison from cardiomegaly secondary to morbid obesity (BMI 54.5). He gained approximately 117kg during his 3-year incarceration, with rapid initial weight gain from …
0y · Male·Trisomy 21 with complex cardiac anomalies complicated by pulmonary hypertension,…
Baby G, born with Trisomy 21 (Down Syndrome) and complex cardiac anomalies, died at Royal Darwin Hospital on 18 March 2023 aged 6 months. The coroner found that non-invasive prenatal testing (NIPT) should have been offer…
5y · Female·myocarditis
A five-year-old girl died from fulminant myocarditis caused by influenza A on 5 July 2022 at Canberra Hospital. The diagnosis was delayed over 7 hours from initial presentation. Critical failures included: ED triage Cate…
27y · Male·Cardiac arrest due to cardiac arrhythmia triggered by prone restraint (some of w…
Michael Peachey, a 27-year-old First Nations man, died in custody following a police-initiated restraint during an acute psychotic episode. Over preceding days, his family repeatedly sought mental health intervention. On…
31y · Female·organ failure due to anorexia nervosa
Chloe Tupper died of organ failure due to severe anorexia nervosa at age 31. She had suffered from this illness for 17 years since age 14, receiving multiple episodes of hospital-based refeeding that never achieved lasti…
61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed
A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…
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