1,172 results
35y · Female·coronary artery dissection
Fiona Selby-Fullgrabe, 35, presented to Wallaroo Hospital with chest pain, arm weakness, and diaphoresis. Ambulance noted elevated troponin (121) and activated the chest pain protocol. However, Dr M. discharged her after…
83y · Female·Pentobarbitone toxicity
Beverley Broadbent, 83, died from pentobarbitone toxicity after deliberately taking a lethal dose to end her life. Her GP, Dr C., who had known of her long-standing intention to die and had even discussed what he might c…
39y · Female·smoke inhalation
Cheryl May Currie, 39, with complete paraplegia from a 1998 spinal cord injury, died from smoke inhalation in a bedroom fire on 12 June 2009. The fire was caused by smoking in bed. Investigation revealed critical systemi…
Female·Verris Dawn Wright: septic shock due to small bowel ischaemia secondary to small…
Two joint inquests examined failures in recognising clinical deterioration in rural hospital patients. Mrs Wright, 86, presented with abdominal pain and a low temperature (early sepsis), but staff did not escalate when s…
66y · Male·carcinomatosis complicated by recurrent sepsis and multisystem failure in a man …
A 66-year-old man with renal cell carcinoma died in hospital from carcinomatosis with sepsis and multisystem failure. Critical clinical lesson: haematuria in 2005 was not adequately investigated with imaging despite recu…
60y · Male·Pulmonary thromboembolism in a man with deep vein thrombosis following a fractur…
A 60-year-old man with obesity, hypertension, and dyslipidemia sustained a fractured right ankle in a motorcycle collision. He presented to ED with chest pain on 3 November but was diagnosed with musculoskeletal pain; EC…
46y · Female·Cardiac arrest of unknown origin
Virginia Brown, a 46-year-old Aboriginal woman, died of cardiac arrest of unknown origin on 31 October 2014 while detained under a Mandatory Residential Treatment (MRT) order at CAAAPU (Central Australian Aboriginal Alco…
39y · Male·combined drug toxicity
Phillip Buckley, 39, died from combined drug toxicity involving oxycontin, diazepam, alcohol and venlafaxine. He had been prescribed high-dose oxycontin (40-80mg daily) and diazepam by his GP Dr C. for 12 years without c…
30y · Female·Fentanyl overdose caused by self-administration of intravenous Fentanyl
Katie Howman, a 30-year-old registered nurse in the Critical Care Ward at Toowoomba Base Hospital, died from an intravenous Fentanyl overdose on 21 December 2013. Autopsy findings of crystalline granulomas in the lungs i…
43y · Male·Ischaemic heart disease
Farin William Daley, aged 43, died of ischaemic heart disease while in custody at Long Bay Correctional Facility. He had suffered a myocardial infarction at age 28 but failed to disclose this medical history during recep…
32y · Male·Mixed drug toxicity (codeine, methadone, alprazolam, diazepam) in a man with cor…
James Dougan, 32-year-old man with longstanding polysubstance abuse, died from mixed drug toxicity (codeine, methadone, alprazolam, diazepam) complicated by severe coronary artery atherosclerosis. He engaged in prescript…
34y · Male·mixed drug overdose (heroin, methadone, codeine, diazepam, nitrazepam, oxazepam …
34-year-old male with longstanding opioid and benzodiazepine dependence who overdosed following discharge from hospital. He was hospitalized on 22 September 2010 after police-observed overdose with altered consciousness.…
86y · Female·right subdural haematoma due to blunt head trauma with contributing excessive wa…
An 86-year-old woman died from subdural haematoma following a minor head injury, complicated by excessive warfarin anticoagulation. She was started on warfarin by a cardiologist on 19 December 2012 for atrial fibrillatio…
60y · Female·hanging
Margaret McCall, a 60-year-old woman with chronic regional pain syndrome and longstanding anxiety and depression, died by hanging. She received multiple ketamine infusions for pain management, with cessation of fentanyl …
47y · Male·Toxic effects of phosphine gas
Jeremy Harding-Roots died from phosphine gas toxicity after deliberately exposing himself to the pesticide fumigant aluminium phosphide (Fumitoxin) during a siege at his former girlfriend's residence. Key clinical and pr…
91y · Male·The combined effects of chest injuries and old age
A 91-year-old man presented to the ED after a motor vehicle crash with chest pain. While imaging revealed abnormalities, ED staff and a junior registrar considered these to be old fractures rather than acute injuries and…
44y · Female·Unascertained
A 44-year-old woman with chronic pain, epilepsy, and opioid dependence died at home with an unascertained cause in the setting of prescription medication use. She was a known 'doctor shopper' who obtained opioids from mu…
34y · Male·Hanging
A 34-year-old man died by suicide by hanging whilst on remand in a correctional facility. He had disclosed his father's suicide 12 years earlier during initial assessment, but was not identified as self-harm risk. In the…
55y · Male·gastrointestinal haemorrhage due to oesophageal varices due to hepatocellular ca…
Robert McIntosh, a 55-year-old prisoner with undiagnosed cirrhosis of the liver, hepatitis C, and hepatocellular carcinoma, died from gastrointestinal haemorrhage and oesophageal varices. While the coroner found that med…
90y · Female·Infected sacral ulcer and fluid imbalances in the context of dementia
A 90-year-old woman with dementia, admitted to aged care in September 2012, developed a large necrotic sacral pressure ulcer despite nursing interventions. She was markedly dehydrated and malnourished, repeatedly refusin…
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