259 results
63y · Male·Aspiration pneumonia in the setting of functional decline in a man with an intel…
A 63-year-old man with intellectual disability, cerebral palsy, dysphagia, and COPD died from aspiration pneumonia following functional decline. He had a three-month hospital admission with multiple complications includi…
59y · Male·Massive aspiration in the setting of intubation following complications of sever…
A 59-year-old man with treatment-resistant schizophrenia on long-term clozapine therapy died from massive aspiration following a severe ileus of unknown aetiology. He had documented constipation managed with laxatives, t…
37y · Male·Pulmonary thromboembolus due to left leg deep vein thrombosis
A 37-year-old Aboriginal man died of pulmonary thromboembolism due to deep vein thrombosis while incarcerated. He presented to hospital on his birthday with lethargy, shortness of breath, and tachycardia. Initial assessm…
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
Maarouf El-Cheikh, a 57-year-old man with splenectomy history, presented to Calvary Hospital ED with sepsis on 21 March 2016 and died 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadeq…
50y · Male·Hanging
A 50-year-old man with Parkinson's disease died by hanging in a psychiatric inpatient unit while on a Temporary Treatment Order. His mental and behavioural symptoms were secondary to Parkinson's disease and its treatment…
76y · Male·Chest sepsis in a man with ischaemic heart disease
A 76-year-old man with multiple myeloma and complex medical history died from chest sepsis and myocardial infarction following a medication dispensing error. After discharge from hospital for spinal compression fractures…
75y · Male·acute bronchopneumonia in a man with comorbidities
A 75-year-old sentenced prisoner died from acute bronchopneumonia with comorbidities. Mr Rice had extensive medical complexity including COPD, cardiac disease, peripheral vascular disease, and diabetes. He was appropriat…
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 …
72y · Female·subdural haemorrhage sustained from a fall from a hospital bed on 18 January 201…
Mrs Judith Gaye Flynn, aged 72, died from a subdural haemorrhage sustained when she fell from a hospital bed on the General Medicine Ward at Canberra Hospital. She was a high-risk fall patient with cognitive impairment, …
40y · Female·Complications of WHO Class III Obesity
Cindy Jane Martin, a 40-year-old Aboriginal woman with treatment-resistant schizophrenia, WHO Class III obesity, and obstructive sleep apnoea, died of sudden cardiac complications seven days after psychiatric admission. …
41y · Male·haemothorax due to ruptured thoracic aortic aneurysm in a man with Marfan syndro…
A 41-year-old man with Marfan syndrome and a thoracic aortic aneurysm managed conservatively with blood pressure medications died from aneurysm rupture while imprisoned. Methylamphetamine in his system significantly elev…
44y · Male·Complications of a Left Temporal Lobe Abscess
Mootijah was a 44-year-old Aboriginal man who died from a brain abscess originating from an untreated chronic ear infection. He had documented hearing impairment and a history of chronic ear disease requiring ENT special…
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…
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…
19y · Female·The available evidence does not allow for a finding as to the cause of death
Helen Stacey, a 19-year-old university student, disappeared on 19 August 1958 after absconding from Broughton Hall mental health facility. She had been referred for urgent psychiatric admission following concerning discl…
59y · Female·Sepsis in a woman with epilepsy, cerebral palsy and haemochromatosis
A 59-year-old woman with cerebral palsy, epilepsy, and intellectual disability died of sepsis from a urinary tract infection (urosepsis) caused by E. coli and Proteus mirabilis. She had four hospital presentations in the…
53y · Male·multiple injuries sustained in a fall from the first floor
Kelvin Forrest, a 53-year-old man with Down syndrome and dementia, died from multiple injuries sustained in a fall from the first floor of Byron Central Hospital on 28 July 2018. He had been admitted as a medical patient…
80y · Male·metastatic oesophageal cancer
Josef Lear, an 80-year-old prisoner, died of metastatic oesophageal cancer at the Royal Darwin Hospital Hospice on 7 March 2021. He presented with progressive dysphagia, cough, and weight loss in mid-2020, which was appr…
54y · Female·unascertained
Carole Livesey, a 54-year-old woman with severe anorexia nervosa and major depression, absconded from Rockingham Hospital psychiatric unit on 3 October 2017 during an escorted walk in hospital grounds. She had been an in…
Male·Complications of alcohol and hepatitis C-related liver disease
Peter Young, an Aboriginal man with advanced alcoholic cirrhosis and recently acquired hepatitis C infection, died of multi-organ failure while on remand in custody. He received appropriate standard medical care in priso…
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