2,427 results
15y · Male·multiple blunt force injuries as a result of being hit by a train
AB, a 15-year-old boy with depression and suicidal ideation, was prescribed Lexapro (escitalopram) by his GP despite it not being registered for use in adolescents. The coroner identified significant failures in clinical…
Male·Faecal peritonitis due to perforated diverticulum
Michael Sutherland presented to Bega Hospital Emergency Department on 2 March 2006 with severe abdominal pain from diverticulitis with bowel perforation. Dr B., the attending Career Medical Officer, formed an unfounded b…
34y · Male·hanging
John Sydney Farmer, aged 34, died by hanging at his home on 23 May 2008, six hours after being granted leave from psychiatric detention at Woodleigh House. He had attempted suicide by carbon monoxide poisoning two days e…
0y · Female·Hypoxic ischaemic encephalopathy due to true knot in umbilical cord
A term infant died from hypoxic ischaemic encephalopathy caused by a true knot in the umbilical cord. The mother presented in labour with spontaneous rupture of membranes and had a prolonged second stage. Foetal heart ra…
39y · Male·pneumococcal meningitis with severe cerebral oedema due to pneumococcal mastoidi…
Jamie Stuart Bais, a 39-year-old man with acute otitis media and sinusitis, was admitted to Flinders Medical Centre for what was thought to be a straightforward ENT infection. Over 15 days, he developed pneumococcal meni…
42y · Male·Hanging (self-inflicted) while suffering from serious mental illness
Brian Dunningham, aged 42, died by hanging at Bathurst Correctional Complex (9–10 September 2009) while in custody. He had serious mental illness (psychosis, depression) requiring antipsychotic and antidepressant medicat…
40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…
Michael Peter Magro, a 40-year-old male inmate at a correctional facility, died on 27 December 2008 from hypoxic brain injury following cardiac disease and severe pneumonia. Critical failures in prison healthcare were id…
1y · Male·Complication of burns and trauma to the mesenteric artery
A 15-month-old child died from complications of severe scalding burns (55% of body) sustained when left unsupervised in a bath of hot water (65°C) for 10-15 minutes, combined with traumatic mesenteric artery tears of unk…
32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …
A 32-year-old woman with schizophrenia, well-controlled on clozapine, became pregnant. Poor communication between her general practitioners, community mental health service, and the hospital meant the hospital was unawar…
41y · Female·acute myocardial infarction
Rebecca Lawrence, a 41-year-old woman with no significant cardiac history, presented to the Royal Adelaide Hospital Emergency Department with chest pain on 4 November 2008. She had experienced a myocardial infarction (AM…
28y · Female·bronchopneumonia complicating oxycodone toxicity
Melissa Jay Tatchell, aged 28 with severe anorexia nervosa (BMI 11.8, weight 29kg), died from bronchopneumonia complicating oxycodone toxicity. A locum doctor with no prior experience with oxycodone prescribed inappropri…
81y · Male·Retropubic and retroperitoneal haemorrhage complicating pelvic fractures with co…
An 81-year-old man died from retropubic and retroperitoneal haemorrhage complicating pelvic fractures sustained in a fall at church. He was on warfarin for atrial fibrillation with an excessive INR of 4.6 at the time of …
0y · Male·Hypovolemic shock, metabolic acidosis and coagulopathy in association with subga…
Owen Appleby, born at Portland Hospital after labour induction, developed hypovolemic shock and died at Warrnambool Hospital 17 hours after birth. Ventouse extraction was used to assist delivery; he was born with low APG…
64y · Male·necrotising fasciitis precipitated by a fishbone perforating his rectum, leading…
James Tranby, a 64-year-old Indigenous diabetic prisoner, presented with a fish bone lodged in his rectum on 3 December 2008. Following removal on 5 December, he developed progressive sepsis leading to necrotising fascii…
Unknown·Gunshot wound to the head (self-inflicted)
Two suicides occurred at a commercial firing range where individuals gained easy access to firearms. Julia Morris, 23, with documented borderline personality disorder and recent suicide attempt, was discharged from hospi…
46y · Male·Coronary artery atherosclerosis
Angelo Lombardo, 45-year-old with schizophrenia, was detained by police under Mental Health Act and brought to ED after acute behavioural disturbance. He received 6mg clonazepam and 20mg olanzapine IM in the ambulance ba…
59y · Female·Subdural haemorrhage from blunt force trauma to head sustained in a backwards fa…
Lena Divola, a 59-year-old woman with intellectual disability, schizophrenia, and depression living in supported accommodation, sustained a head injury on 24 December 2007 when she fell backwards from a walker being push…
91y · Female·traumatic subarachnoid haemorrhage and acute and chronic subdural haematoma as a…
91-year-old admitted to high-care aged care facility (Bennelong House) on 14 October 2009 following stroke and multiple falls. Within one hour of arrival, she fell from bed and lay on the floor for approximately 45 minut…
11y · Female·Sepsis due to acute peritonitis secondary to perforated gangrenous acute appendi…
Hannah Fowler, aged 11, died from sepsis secondary to perforated gangrenous acute appendicitis. She presented with progressive abdominal pain, vomiting, anorexia and malaise over four days before sudden deterioration and…
14y · Male·injuries sustained in fall from height
Aaron, aged 14, died by suicide from a fall from an 11th-floor balcony. Over 12 years, he had 14 child protection notifications for exposure to domestic violence, neglect, parental substance misuse, poor school attendanc…
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