259 results
44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)
Jimmy James, a 44-year-old man, died from pneumonia with multiple left-sided rib fractures secondary to a physical assault. He presented to Westmead Hospital ED with clinical signs of septic shock (tachypnoea, hypoxia, h…
91y · Male·Hypostatic pneumonia due to traumatic fracture of C7 and subluxation of C6/7, re…
Maxwell Delaney, 91, was a resident at Eliza Purton Care Home in Tasmania with complex medical history including Alzheimer's disease, osteoporosis, and prior falls. On 24 January 2015, he fell while seated on a lightweig…
33y · Male·presumed fatal cardiac arrhythmia in the presence of coronary artery atheroscler…
Dr D., a 33-year-old physicist, was admitted to Hornsby Hospital on 27 December 2012 with abdominal pain, nausea, vomiting and joint pain. His presentation included hypotension (97/61), tachycardia (116/min), hyponatraem…
59y · Male·Cardiac arrest caused by Ischaemic Heart Disease
Angus Dixon, a 59-year-old Aboriginal man with ischaemic heart disease, diabetes, and a history of paranoid psychosis, died from acute myocardial infarction while an involuntary mental health patient at Alice Springs Hos…
Female·Multiple injuries
Yvonne Henderson was a middle-aged woman with chronic delusional disorder who died in a motor vehicle collision on 6 December 2010 while on approved leave from psychiatric hospitalisation. She was an involuntary patient …
58y · Female·Multiple injuries sustained in collision with train (pedestrian)
Elaine Sykes, aged 58, was admitted to Dandenong Hospital with acute renal failure and severe mental health deterioration. After 47 days at Acacia Mental Health Unit, she demonstrated substantial improvement and was disc…
52y · Female·intracerebral haemorrhage in a lady with underlying cerebrovascular disease and …
A 52-year-old woman underwent right carotid endarterectomy for high-grade stenosis. Post-operatively she developed escalating blood pressure readings (160–220 mmHg), headaches, nausea, agitation, and abnormal behaviour o…
40y · Male·Aspiration pneumonia
Jeffrey McCarty, a 40-year-old man with cerebral palsy, severe intellectual disability, dysphagia and recurrent aspiration pneumonia, died from aspiration pneumonia after being placed on a palliative pathway. The coroner…
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 …
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…
33y · Male·Multiple injuries sustained from falling from height (fifth-floor window ledge) …
AB, a 33-year-old male, died on 20 April 2013 after falling from the fifth-floor window ledge of Liverpool Hospital while under police negotiation. He had been transferred from prison to immigration detention on 9 April …
21y · Male·Sepsis caused by Leptospirosis (Graeme Gulliver); Group A streptococcal meningit…
Three young patients died from severe bacterial infections at rural Queensland hospitals (Mossman and Atherton). All three received delayed diagnoses and treatment. The first patient (21-year-old with leptospirosis) pres…
76y · Male·exsanguination secondary to pulmonary aortic fistula and thoracic aorta aneurysm…
Allan Phipps was a 76-year-old man with a known thoracic aortic aneurysm and severe depression admitted to Austin Hospital in October 2012 for unstable angina and depression management. His aneurysm, discovered in March …
42y · Male·Cardiac arrhythmia secondary to electrolyte imbalance (hyperkalaemia) and verapa…
Glen Kingsun, 42, died from cardiac arrhythmia secondary to electrolyte imbalance and verapamil toxicity. He had complex medical needs requiring multiple specialist and GP care. Critical failures occurred: (1) Medication…
71y · Female·Diffuse Lymphoid Malignancy
Mary Una Barnett, a 71-year-old woman in custody at Dame Phyllis Frost Centre, died from diffuse lymphoid malignancy (high-grade lymphoma) discovered shortly before her death. She had extensive comorbidities including ch…
69y · Male·asphyxia by hanging
A 69-year-old man with depression, prostate cancer, and recent suicide attempt was admitted to MAPU (general medical ward) after intensive care treatment. He was deemed low suicide risk and the one-on-one attendant was d…
61y · Female·Peritonitis due to anastomotic leak at gastrectomy site; pathological obesity as…
A 61-year-old woman with pathological obesity died from peritonitis secondary to anastomotic leak following laparoscopic sleeve gastrectomy. The procedure itself was appropriate for her failed previous lap band surgeries…
70y · Female·Aspiration pneumonia, associated with Huntington's disease
Beryl Watson, a severely disabled 70-year-old with advanced Huntington's disease and dementia, died of aspiration pneumonia following a three-week respite stay at a BUPA aged care facility. Critical failures included: om…
84y · Female·Major cerebral infarct due to hypoglycaemia
Marie Goder, an 84-year-old with diabetes, developed severe hypoglycaemia following insulin administration at a nursing home on 1 November 2009, resulting in prolonged unconsciousness and bilateral cerebral infarcts. Aft…
76y · Female·colchicine toxicity
A 76-year-old woman with gout died from colchicine toxicity after being prescribed 500µg three times daily on 9 December 2010 for an acute attack. She developed diarrhoea from 15 December and died on 19 December with a p…
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