4,457 results
3y · Male·Hypoxic ischaemic encephalopathy complicating hypoglycaemia with shock and statu…
A 3-year-old boy with septo-optic dysplasia and panhypopituitarism died from hypoxic ischaemic encephalopathy secondary to adrenal crisis and hypoglycaemic shock. He was in state care and had an emergency management plan…
6y · Male·cardiopulmonary arrest on a background of earlier cardiac arrests and resuscitat…
Austin Facer, a 6-year-old boy, suffered multiple cardiac arrests at school on 21 October 2019, initially resuscitated successfully, but died during transfer preparation to a higher-level hospital that evening. Autopsy r…
45y · Male·stab injury to the chest
Paul Kenneth Wright, aged 45, died from a stab wound to the chest inflicted in self-defence by Beau Muscat on 16 September 2021. Paul had an extensive custodial history, acquired brain injury, and intellectual disability…
41y · Female·Multiple injuries
Alicia Maree Little, aged 41, was struck and killed by a motor vehicle driven by her former intimate partner while she was leaving the relationship. The case highlights significant systemic failures in family violence re…
30y · Male·Gunshot wounds to the chest
Gabriel Messo, a 30-year-old man with bipolar affective disorder, died from gunshot wounds inflicted by Victoria Police on 16 July 2020 after violently assaulting his mother at John Coutts Reserve. Clinical lessons inclu…
74y · Male·Pericarditis post aortic valve surgery with large pericardial effusion leading t…
Ian Dunlop, a 74-year-old man, died from pericarditis with large pericardial effusion and tamponade four days after aortic valve replacement surgery. Post-operative imaging showed a small pericardial effusion, considered…
3y · Male·Smoke inhalation
A 3-year-old boy died from smoke inhalation after a fire in his mother's public housing apartment. The fire likely originated when the child transferred a lit object from the stove to a couch. The mother attempted to use…
58y · Male·complications of large bowel pseudo-obstruction
Paul Desmond Smith, aged 58, died from complications of large bowel pseudo-obstruction following discharge from hospital after inadequate assessment. He had presented to the ED with lower abdominal pain and severe faecal…
68y · Male·traumatic brain injury due to a gunshot wound to the head
A 68-year-old man with history of depression, heavy smoking, excessive alcohol consumption, and prior bowel cancer shot himself fatally with a licensed firearm. He had been assessed as 'fit and proper' to hold his firear…
41y · Male·Gunshot wounds to the head and torso
Duy Linh Ho, a 41-year-old man with long-standing substance use disorder and untreated mental health issues, died from gunshot wounds after a police response to his self-harm and suicidal crisis. He had used methamphetam…
30y · Male·Cyanide poisoning
A 30-year-old teacher in regional Victoria died from cyanide poisoning in June 2020. He presented to his GP in February 2020 with atypical features including fear of being poisoned, which raised concerns for possible psy…
43y · Male·Hanging
William Epere, aged 43, died by hanging in custody at Dawn de Loas Correctional Centre on 10 January 2019. He had been remanded in custody for 27 days following repeated breaches of a domestic violence order, despite cle…
59y · Male·complications of viral liver cirrhosis with hepatocellular carcinoma
Mervyn Morgan, aged 59, died from complications of hepatocellular carcinoma arising from cirrhosis while in prison custody. Critical failures included: delayed monitoring of known liver cirrhosis (no ultrasound despite M…
46y · Male·Cold environmental exposure in a man with cardiomegaly
Carl Robert Adler, a 46-year-old man with treatment-resistant schizophrenia, intellectual disability, and autism, died from cold environmental exposure complicated by pre-existing cardiomegaly after leaving a community c…
23y · Male·Undetermined
A 23-year-old male died from an undetermined cause following a night of cocaine and nitrous oxide use. He experienced paranoid and delusional thoughts, hallucinations about demonic possession, and reported chest pain and…
89y · Male·septicaemia due to infected groin wound, femoropopliteal bypass in a man with mu…
An 89-year-old man with multiple comorbidities (diabetes, peripheral vascular disease, heart failure) developed a groin wound infection following femoropopliteal bypass surgery while residing in aged care. The wound dete…
90y · Female·Multiple rib and pelvic fractures due to a fall from a wheelchair on sloping lan…
Cynthia Stevens, aged 90, died from multiple fractures sustained when her wheelchair rolled uncontrolled down a steep slope in a medical car park. The primary clinical lessons include: (1) inadequate application of wheel…
44y · Male·gunshot wound to the abdomen
Vlado Micetic, 44, was fatally shot by Leading Senior Constable Timothy Baker during a traffic interception for stolen number plates in Windsor, Victoria, on 25 August 2013. Baker claimed Micetic produced a knife during …
42y · Female·Multiple stab wounds
A 42-year-old woman with first episode psychosis was referred to community mental health services in November 2020 after acute onset of paranoid delusions. She was commenced on risperidone but showed poor engagement and …
5y · Female·Multiple stab wounds to the back
Anna Perinovic, age 5, died from multiple stab wounds inflicted by her mother Katica during a first episode psychosis. Katica had been referred to NorthWestern Mental Health in November 2020 after developing paranoid tho…
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