4,457 results
7y · Female·Pneumonia complicating a viral respiratory illness with acute combined drug effe…
Child ML, aged 7, died of pneumonia complicating viral respiratory illness with acute combined drug effect. She had severe cerebral palsy with complex care needs including PEJ tube feeding and multiple medications. At th…
58y · Male·acute bronchopneumonia
Giovanni Trotta, aged 58, died in custody from acute bronchopneumonia. He was a vulnerable prisoner with COPD, schizoaffective disorder, and profound deafness. Clinical lessons include: (1) hospital discharge summaries m…
4y · Female·Drowning
A 4-year-old girl from an Afghan refugee family drowned in Lysterfield Lake after entering the water during a brief lapse of supervision. She was unable to swim and had not received water safety education. Despite immedi…
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…
20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…
Adam Fitzpatrick, a 20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged…
2y · Unknown·Hypoxic-ischaemic encephalopathy following sepsis related to abdominal surgical …
BCT was a 2-year-old Aboriginal child with complex needs from a genetic disorder (CAMTA1 mutation) who died from hypoxic-ischaemic encephalopathy following sepsis related to bowel perforation after a percutaneous endosco…
29y · Male·Methadone toxicity
Darren James Fielding died in custody at Middleton Prison on 26 May 2018 from methadone toxicity. He was on day 6 of opioid substitution therapy (OSTP) when he received his prescribed 10mg methadone dose. Expert evidence…
40y · Male·Full thickness burns to body in the setting of self-immolation
A 40-year-old Tamil asylum seeker died from full thickness burns sustained during self-immolation on 20 August 2021. The death occurred three days after Victoria Police attended a family violence incident where KK assaul…
29y · Male·Effects of fire
Manmeet Sharma, a 29-year-old bus driver, was killed on 28 October 2016 when Anthony O'Donohue, an untreated patient with severe psychotic illness characterised by persecutory delusions, boarded his bus and set him on fi…
74y · Female·Cardiac arrest due to pulmonary embolism secondary to deep venous thrombosis
A 74-year-old woman presented to ED with left leg swelling and calf pain. She was triaged as category 4 and seen by a doctor after a 4-hour 24-minute delay due to staff shortages and access block. A D-Dimer test showed e…
2y · Female·effects of fire (smoke inhalation and thermal injury)
AW, a 2-year-old girl with 15a11.2 BP1-BP2 microdeletion syndrome and developmental delays, died on 14 April 2018 in a house fire at her rural NSW home. She died from smoke inhalation and thermal injury. The fire's exact…
0y · Male·suffocation due to overlay by a sleeping adult
A 59-day-old premature infant died from suffocation due to overlay by a sleeping parent. The infant was placed on a mattress next to the parent's cot after refusing to settle in his own cot. Despite the parent's attempt …
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…
15y · Male·Electrocution
JH, a 15-year-old with Autism Spectrum Disorder and Major Depressive Disorder, died by electrocution at home on 16 September 2019. He had been experiencing suicidal ideation for months and was discharged from inpatient p…
62y · Male·cardiac arrest complicating psychotic episode
Michael Adams, aged 62 with chronic treatment-resistant schizophrenia, died from cardiac arrest complicating psychotic episode at a supported residential facility. During escalating psychotic behaviour, paramedics applie…
17y · Female·multiple injuries
Afrikah Rose Pearl Philp, aged 17, died from multiple injuries sustained in a high-speed vehicle collision on 6 October 2017 while being pursued by police. She had a complex medical history including psychogenic non-epil…
36y · Female·Stab wound to the right chest
Amanda Jane Harris, 36, was fatally stabbed by her intimate partner Daniel Eckersley on 7 July 2018 in Cranbourne North, Victoria. Eckersley was prescribed high-dose tramadol (700-800mg daily) for chronic pain over 22 mo…
74y · Female·Fractures of the legs, with terminal palliative care, in an elderly lady with mu…
Ms Papanastasiou, a 74-year-old aged care resident confined to a wheelchair, died from bilateral femoral fractures sustained when she fell from her wheelchair during sudden bus braking. The wheelchair was secured using o…
82y · Female·traumatic closed head injury (subdural haematoma) resulting from a fall from sta…
Mrs Emily Jones, 82, died from subdural haematoma following an unwitnessed fall at Royal Hobart Hospital on 15 November 2021. She was admitted five days after discharge from Hobart Private Hospital where she was treated …
68y · Male·Sudden cardiac death due to congestive cardiac failure and chronic obstructive p…
Wayne Victor Rouse, 68, died from sudden cardiac death at a residential aged care facility when CPR was not provided despite his active resuscitation order. Staff incorrectly believed he had a 'do not resuscitate' order …
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