1,172 results
15y · Male·Hanging (redacted in original but indicated by reference to method of suicide)
A 15-year-old boy with depression died by suicide. He had a difficult relationship with his parents and was reluctant to engage with mental health services. A clinical psychologist assessed him as low-moderate suicide ri…
94y · Female·Sepsis complicating management of vulval carcinoma in an elderly woman with seve…
A 94-year-old woman with vulval carcinoma underwent suprapubic catheter insertion at a private hospital on 14 May 2014. She appeared well post-procedure with normal observations. The following day, she was transferred by…
49y · Male·complications of non-small cell carcinoma of the lung
Keith Howlett, 49 years old, died from complications of non-small cell carcinoma of the lung while in custody at Junee Correctional Centre after 5 weeks of incarceration. He had complex medical needs including HIV, perip…
55y · Male·Septicaemia due to hydronephrosis and infection
A 55-year-old man with complex medical and social problems died of septicaemia from renal infection. He had a history of cardiac disease requiring anticoagulation, alcohol dependence, depression, and chronic hoarding beh…
0y · Female·acute necrotising pneumonia
Masaly Mosby, a 36-day-old Aboriginal infant, died from acute necrotising pneumonia after presenting to Broome Hospital Emergency Department three times in four days but never being seen by a doctor for formal assessment…
49y · Male·ligature compression of the neck (hanging)
Barry Matt Stuart, a 49-year-old prisoner at Hakea Prison, died by suicide via ligature compression of the neck in November 2013. Critical clinical lessons include: (1) maintaining psychiatric continuity of care is essen…
56y · Male·Aspiration of gastric content secondary to combined drug toxicity
A 56-year-old de-registered doctor died from aspiration of gastric content secondary to combined drug toxicity. He had a long history of prescription drug dependency and multiple mental health issues. Two general practit…
48y · Male·Injuries sustained when struck by a train
A 48-year-old man with mental health issues including depression and possible bipolar disorder died by suicide following train strike. He had a complex presentation with diagnostic uncertainty between bipolar affective d…
87y · Female·Multiple opioid drug toxicity (morphine and fentanyl) in combination with conges…
An 87-year-old woman with multiple comorbidities (ischaemic heart disease, emphysema, chronic kidney disease) was discharged home for palliative care after a hospital admission. Her family administered excessive doses of…
10y · Female·Multi-organ failure secondary to overwhelming herpes simplex virus (HSV) infecti…
A 10-year-old girl died from multi-organ failure secondary to overwhelming herpes simplex virus (HSV) infection. She presented to the Women's and Children's Hospital on day 3 of pharyngitis with ulceration of the tonsill…
23y · Female·chronic hydrocephalus with brain swelling
A 23-year-old registered nurse with undiagnosed chronic hydrocephalus presented to the ED with neck pain, headache and vomiting. Dr B. assessed her briefly without formal examination or detailed history, prescribed ketor…
47y · Female·Multiple injuries from being struck by a train; death determined to be suicide
A 47-year-old woman with bipolar affective disorder and PTSD, originally from Bosnia, died by suicide by stepping in front of a train on 1 May 2012. She was subject to a Community Treatment Order at the time. Critical cl…
73y · Male·Stab wound to the neck
Harold Nolan, 73, was fatally stabbed in the neck by his ex-wife Renee Nolan while asleep at home. Ms Nolan was his full-time carer following his 2013 stroke and was experiencing severe carer fatigue, mental health deter…
50y · Female·Hanging
Jacinta Dwyer, a newly appointed magistrate with limited criminal law experience, developed severe anxiety and depression within months of taking office in February 2017. Despite supportive interventions from senior judg…
29y · Female·peritonitis caused by ischaemia of the bowel due to gastrointestinal torsion (tw…
Shona Hookey, a 29-year-old Aboriginal woman with severe intellectual disability and aphasia, died of peritonitis secondary to bowel torsion. Critical failures occurred at multiple levels: carers at her group home delaye…
75y · Female·multiple injuries due to or as a consequence of motor vehicle collision
Ruth Capps, 75, died in a motor vehicle collision after drifting into oncoming traffic. She had multiple medical conditions including diabetes, sleep apnoea, chronic back pain, osteoarthritis, and recurrent falls. Despit…
21y · Male·combined effect of a cocktail of drugs taken by him, which caused central nervou…
Paul Fennessy, 21 years old, died from a cocktail of drugs causing central nervous system and respiratory depression with positional asphyxia on 6 January 2010. He had a decade-long history of polysubstance abuse, doctor…
21y · Male·combined effect of a cocktail of drugs causing central nervous system depression…
Paul Fennessy, a 21-year-old with polysubstance addiction and mental health issues, died from positional asphyxia following a drug overdose on 6 January 2010. He presented to the Emergency Department that afternoon after…
58y · Male·blunt force head injury
Frederick Peisley, an Aboriginal man with acquired brain injury and schizoaffective disorder, died from a head injury after falling from stairs at an aged care facility. Critical failures included poor communication of h…
16y · Female·mixed drug toxicity (oxycodone, citalopram, fluoxetine and quetiapine)
JF, aged 16, died by intentional overdose of prescription medications after being removed from her long-term foster home. JF had a history of depression, borderline personality disorder, reactive attachment disorder, and…
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