259 results
65y · Female·choking on a tangerine
Ms Shelley Young, a 65-year-old woman with long-standing schizoaffective disorder and multiple complications from chronic antipsychotic use including dysphagia and tardive dyskinesia, died from choking on a tangerine whi…
36y · Male·Complications of morbid obesity, including cardiac enlargement, aspiration of ga…
A 36-year-old man with treatment-resistant schizophrenia and Capgras syndrome died from complications of morbid obesity (183.5 kg, BMI 45.3). He was discharged from hospital on 14 January 2019 after admission for respira…
68y · Male·Metastatic Pancreatic Adenocarcinoma
Ivan Leo Goolagong, a 68-year-old Wiradjuri man, died of metastatic pancreatic adenocarcinoma while in Long Bay Prison Hospital Medical Subacute Unit in July 2017, five months after undergoing a Whipple procedure. The co…
78y · Male·cardiorespiratory failure due to complications of tracheal stenosis
Bruce Hodges, a 78-year-old man with a 20-year-old tracheostomy following laryngeal cancer surgery, presented to hospital with progressive shortness of breath and tracheal stenosis. Over 48 hours of admission, his respir…
86y · Female·Plastic bag asphyxia
An 86-year-old woman with delirium, depression, and multiple cardiac comorbidities died by asphyxiation with a plastic bag while in a transitional care facility. She had expressed wishes to die, references to suicide, an…
43y · Male·Hanging
A 43-year-old man remanded in custody for serious sexual offences against children died by hanging in an older prison cell. While he expressed fears about safety and had passive suicidal ideation months before his death,…
68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…
Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mi…
48y · Male·Coronary atherosclerosis with acute cardiac event
Richard William Hobbs, aged 48, died from cardiac arrest in custody at Brisbane Correctional Centre on 21 November 2017. He had significant comorbidities including coronary artery disease (recent stent insertion), diabet…
42y · Male·ligature compression of the neck (hanging)
Wayne Larder, a 42-year-old man with depression, suicidal ideation, and substance use disorder, died by hanging in Hakea Prison on 22 February 2021. Critical failures in suicide risk management included: (1) mental healt…
65y · Male·ischaemic and hypertensive heart disease with contributing acute cholecystitis (…
A 65-year-old man with hypertension presented with acute cholecystitis, underwent laparoscopic cholecystectomy, and initially recovered well. On post-operative day 7, he experienced chest pain radiating to his jaw. Two E…
67y · Male·Head injuries sustained from a fall from the upstairs landing in Goldsmith G Blo…
Ye Chiu, a 67-year-old Chinese-speaking prisoner on remand, died by suicide in prison on 6 February 2017 after falling head-first from a landing. He had a complex psychiatric history including anxiety, depression, hypona…
0y · Male·Complications in association with fulminant sepsis in an infant (Streptococcus p…
Malakai Paraone, a seven-month-old infant, died from fulminant Streptococcus pyogenes sepsis and septic shock. Over three days, he was seen at three hospitals and a general practice clinic but sepsis was not identified. …
85y · Female·Multisystem failure complicating ischaemic heart disease and ischaemic bowel in …
Lydia Maxfield, 85, died 5 days after elective left total knee replacement at a private hospital from multisystem failure due to ischaemic heart disease and ischaemic bowel. Critical clinical lessons: (1) Multiple abnorm…
61y · Male·Undetermined
Gerard Guy Vaz, a 61-year-old man with bipolar disorder, obstructive sleep apnoea, and renal impairment, was admitted to Maroondah Hospital on 2 April 2015 with acute manic relapse with psychosis. He was administered zuc…
60y · Female·Respiratory arrest in the setting of aspiration pneumonia; seizures associated w…
A 60-year-old woman with Down syndrome, Alzheimer's dementia, and epilepsy died from respiratory arrest due to aspiration pneumonia after a seizure. A multi-day delay in anticonvulsant medication (phenytoin) occurred due…
68y · Male·Pulmonary thromboembolus secondary to deep vein thrombosis
Ronald Wood, a 68-year-old with complex medical history including prior pulmonary emboli, was treated for rectal cancer requiring chemotherapy and major surgery. Warfarin anticoagulation was appropriately ceased due to b…
42y · Male·Aspiration pneumonia in the setting of impacted large bowel in a man with intell…
Chris Perdios, a 42-year-old man with intellectual disability, autism, and chronic constipation, died from aspiration pneumonia complicated by an impacted large bowel. He was admitted to hospital on 12 October 2018 with …
68y · Female·Sepsis (Enterobacter cloacae) due to peritonitis as a consequence of leaking per…
A 68-year-old woman with oculopharyngeal muscular dystrophy died from sepsis due to peritonitis following dislodgement of a PEG tube inserted on 27 February 2018. She presented to a rural hospital 5.5 hours post-discharg…
67y · Female·bronchopneumonia and acute liver failure on a background of liver cirrhosis and …
Valerie Kelly, a 67-year-old woman with cirrhosis, hepatocellular carcinoma, and multiple comorbidities, died at Royal Perth Hospital from bronchopneumonia and acute liver failure. She was in custody at Bandyup Women's P…
45y · Male·Global cerebral hypoxia following cardio-respiratory collapse due to anaphylaxis…
A 45-year-old man with poorly controlled diabetes, ischaemic heart disease, and recurrent lower limb infections died from anaphylaxis to intravenously administered flucloxacillin. He presented with sepsis secondary to a …
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