2,427 results
73y · Male·ischaemic heart disease due to coronary atherosclerosis
A 73-year-old man found a purse at a shopping centre and attempted to leave his details with the information desk rather than hand it in directly. A security officer, believing him suspicious, confronted, accused him of …
55y · Male·Immersion (Drowning) arising by way of suicide
Peter Daniel Mahoney, a 55-year-old man with treatment-resistant bipolar affective disorder, died by drowning on 13 June 2003 after absconding from Joondalup Health Campus where he was detained as an involuntary patient …
25y · Male·cerebral craniopharyngioma
Gregory Andrew Furniss, a 25-year-old male with a history of asthma and congenital cataracts, presented to Swan District Hospital on 11 August 2002 with a persistent headache. He was seen by Dr H. (registrar) who diagnos…
41y · Male·haemorrhage due to incised wounds to left and right cubital fossae
Jeffrey Ronald Fredericks, aged 41, died in Adelaide Remand Centre custody from haemorrhage due to self-inflicted incised wounds to both cubital fossae. Critical clinical lessons: screening tools identified significant s…
36y · Male·hanging
Troy Phillip Turner, aged 36, died by hanging in his prison cell on 2 September 2001 while on remand for serious domestic violence-related offences. The coroner identified several preventable failures: (1) Duty Superviso…
35y · Male·left lower lobe pneumonia
Stephen John Power died of left lower lobe pneumonia on 5 September 2003 after two failed emergency calls requesting ambulance assistance. On Thursday 4 September, dispatcher Coralie Holland failed to send an ambulance d…
12y · Female·raised intracranial pressure due to ventriculo-peritoneal shunt blockage
A 12-year-old girl with congenital hydrocephalus and a ventriculo-peritoneal shunt presented to the ED with severe unrelieved headache after head trauma. An inexperienced junior doctor (6 weeks in role, minimal neurosurg…
55y · Male·Head injury from a fall, contributed to by chronic alcoholism and cirrhosis, res…
John Henry Colbert, a 55-year-old man with chronic alcoholism, Wernicke's encephalitis and cirrhosis, was admitted to Royal Darwin Hospital's ICU following a seizure. He was transferred to Ward 4A on 14 October 2002 and …
41y · Female·Peritonitis following surgical procedure to the urinary bladder, due to infected…
Cheryl Lee Edmiston, a healthy 41-year-old woman, died of peritonitis and sepsis following minor bladder procedures (cystoscopy, hydrodilatation, and biopsy) at Joondalup Health Campus on 14 February 2003. The biopsies w…
37y · Male·Acute Aspiration Pneumonitis following on Quetiapine Ingestion
Paul John Long, a 37-year-old man with chronic schizoaffective disorder and alcohol dependence, died on 4 November 2002 from acute aspiration pneumonitis following quetiapine overdose. After presenting to Avro Clinic in …
60y · Female·haemorrhagic shock and respiratory failure due to right-sided haemothorax compli…
A 60-year-old woman with metastatic breast cancer and COAD died from haemorrhagic shock due to right-sided haemothorax complicating thoracentesis. The procedure was appropriately performed to drain a pleural effusion on …
27y · Male·Not determined; olanzapine toxicity suspected but regarded by expert evidence as…
Michael Jason Taylor, aged 27, died on 26 February 2000 while detained at Glenside Hospital under the Mental Health Act 1993. He was a patient with chronic schizophrenia, borderline intelligence, and a history of drug-se…
25y · Female·Ligature Compression of the Neck (Hanging)
Natasha Quartermaine, a 25-year-old female prisoner at Bandyup Women's Prison in Western Australia, died by suicide via ligature compression of the neck on 27 August 2001. She had a long history of mental illness, person…
57y · Male·Multiple organ failure in consequence of peritonitis resulting from complication…
Robert Douglas Dalgleish died from multiple organ failure due to peritonitis resulting from complications of gastric banding surgery. He presented to the ED on 18 July 2002 with abdominal pain and vomiting. Dr B. appropr…
26y · Male·Ligature Compression of the Neck (Hanging)
Dylan Robert Green, a 26-year-old remand prisoner at Hakea Prison, died by hanging on 11 July 2002. He had a history of serious mental illness, including psychotic episodes with delusional beliefs, and a previous suicide…
Eva Arany: gunshot wound to the neck; Jeno Arany: traumatic brain damage complic…
An elderly man with severe depression, suicidal ideation, and ongoing psychiatric risk was hospitalised twice in 2000 and discharged on antidepressant medication. Despite staff identifying he owned seven firearms and pos…
41y · Female·secondary haemorrhage following gastric banding surgery
A 41-year-old enrolled nurse died from secondary haemorrhage eight days after laparoscopic gastric banding surgery in Darwin. She attended ED on 18 February with post-operative pain; Dr McNair discharged her after two ho…
34y · Male·extensive blood loss from acute gastric erosions following severe scalding of th…
Neil Summerell, a 34-year-old man with intellectual disability, epilepsy, and vision/hearing impairment, died from acute gastric erosions following severe scalding injuries sustained on 29 November 1999. He was scalded t…
33y · Female·Raised intracranial pressure secondary to thrombosis of the superior sagittal, t…
A 33-year-old woman presented with acute neurological symptoms (headaches, weakness, slurred speech, seizures) on 26 August 2000. Initial CT imaging showed focal haemorrhage with oedema; repeat CT after 50 minutes showed…
19y · Female·hypoxic encephalopathy as a result of attempted hanging
A 19-year-old woman with psychosis and depression died from hypoxic encephalopathy following attempted hanging while in involuntary psychiatric admission. She was on R15 (15-minute) observation status due to suicide risk…
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