136 results
48y · Female·Hypoxic ischaemic encephalopathy due to pulmonary thromboembolism due to deep ve…
A 48-year-old woman with morbid obesity and smoking history presented to a rural hospital with severe hip and leg pain. Over five days across two hospitals, no venous thromboembolism (VTE) risk assessment was performed d…
92y · Female·Consequences of an assault
A 92-year-old woman with dementia died from consequences of an assault by another resident with unmanaged psychosis in an aged care facility. The assault occurred after the facility failed to adequately monitor, assess, …
37y · Male·Sudden unexpected death in epilepsy (SUDEP) in the setting of acquired brain inj…
Kieran McGuinness, 37, died of sudden unexpected death in epilepsy (SUDEP) following acquired brain injury with post-traumatic epilepsy. He was found unresponsive on his apartment floor on 11 September 2022, having been …
81y · Male·Head injury sustained in a fall
Michele Valentino, 81, died from a head injury sustained in a fall on 20 December 2019, with death occurring on 24 December 2019. A CT angiogram at 3:45pm showed worsening intraventricular haemorrhage (IVH) that was not …
73y · Male·Combined effects of cerebrovascular accident and subsequent iatrogenic related i…
A 73-year-old man presented to ED with acute facial droop and speech difficulty on 5 September 2020. He was misdiagnosed with Bell's palsy despite clinical features suggestive of stroke. A non-contrast CT brain (inadequa…
61y · Male·Pulmonary aspiration of gastric contents (post seizure) due to chronic communica…
Michael Phillip Hyde-Wyatt, aged 61, died from pulmonary aspiration of gastric contents following a seizure. He had chronic communicating hydrocephalus and encephalomalacia. At 1:30am, support worker Julie Magrath observ…
36y · Male·Bronchopneumonia in a man with epilepsy
Jonathan Palmer, a 36-year-old man with epilepsy and intellectual disability living in a group home, died from bronchopneumonia on 24 February 2018. On 23 February, he developed respiratory symptoms (coughing, runny nose…
33y · Male·Prolonged epileptic seizure resulting in gastric content aspiration and cardiac …
Roy Roberts, a 33-year-old Aboriginal man, died at Long Bay Correctional Complex from a prolonged epileptic seizure resulting in aspiration and cardiac arrest. He had experienced three prior seizure-like episodes in Apri…
72y · Female·Pneumonia following cervical spine injuries sustained in an unwitnessed mechanic…
Valma Ann Tweedie, aged 72, died from pneumonia following cervical spine injuries sustained in an unwitnessed fall at a disability support facility. She had a known history of falls, mobility problems, and probable demen…
53y · Male·intracerebral haemorrhage
William Anderson, an Aboriginal man aged 53, suffered a catastrophic intracerebral haemorrhage while imprisoned and died despite timely emergency response. Multiple delays occurred: 25 minutes before the cell was opened,…
19y · Male·unable to be determined
Nazrawi Woldemichael, a 19-year-old with a history of severe mental illness, traumatic brain injury, suicidal ideation, and substance abuse, disappeared on 9 October 2016 from North Hobart. The coroner determined he is d…
63y · Female·Escherichia coli septicaemia in a lady with multiple comorbidities
Helen Welsh, 63, died from E. coli septicaemia with multiple comorbidities. She presented with respiratory symptoms and underwent bronchoscopy. On discharge day, she deteriorated with fever, altered consciousness, and hy…
57y · Male·brainstem and cerebellar infarction due to vertebrobasilar artery thrombosis
A 57-year-old man with multiple cardiovascular risk factors presented to an ED with vertigo, blurred vision, and 'not feeling right' caused by an evolving posterior circulation stroke. A junior doctor discharged him afte…
0y · Male·Acute traumatic head injury (non-accidental)
A 7-month-old child died from acute traumatic head injury sustained from non-accidental blunt force. Clinical lessons include: medical staff should strongly reinforce urgent referrals (the child had a critical GP referra…
76y · Male·Intracranial haemorrhage
Charles Bertram Squires, a 76-year-old prisoner on anticoagulant therapy (apixaban and aspirin), fell and struck his head on 26 January 2017. Nursing staff at the correctional facility inadequately assessed his traumatic…
54y · Male·Neck injuries sustained in a fall - fracture of the fifth cervical vertebra (car…
Wayne Myhill, aged 54, died from a cervical spine fracture (C5 level) sustained in a fall at his group home in Ararat, Victoria. He had cerebral palsy, intellectual disability, Lennox-Gastaut syndrome with frequent seizu…
83y · Female·Aspiration bronchopneumonia in a setting of cerebral infarction
Ms Patricia Grant, 83, died from aspiration bronchopneumonia following cerebral infarction while living with her son and daughter-in-law. She experienced severe neglect and elder abuse in her final years: cessation of ep…
45y · Male·Recurrence of ventricular fibrillation due to Brugada Syndrome
Craig Williams, 45, suffered an out-of-hospital cardiac arrest in 2015 due to presumptive Brugada Syndrome. He survived with severe hypoxic brain injury and spent 10 months rehabilitating at Cairns Hospital, where he was…
60y · Female·acute cerebral bleed resulting from blunt trauma and late haemorrhagic progressi…
Gwenith Elkington, aged 60, died from acute cerebral bleed resulting from haemorrhagic progression of a traumatic brain injury sustained in a bathroom fall on 21 September 2015. The injury caused a contre coup contusion …
49y · Female and male·Gunshot wound to head inflicted by spouse
Karina Lock was fatally shot by her husband Stephen Lock in a murder-suicide at a McDonald's restaurant on 10 September 2015. The coroner identified multiple systemic failures that failed to protect Ms Lock despite her h…
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