2,427 results
36y · Male·infective endocarditis
John Clive Anderson, a 36-year-old prisoner, died from infective endocarditis despite being evaluated 25 times by prison medical officer Dr P. between February and May 2009. Dr P. documented possible infective endocardit…
47y · Female·acute subendocardial septal myocardial infarction complicating hypertension and …
A 47-year-old woman with hypertension, high cholesterol, and significant family history of early cardiac disease presented to a country hospital ED with acute crushing central chest pain (10/10), shortness of breath, and…
35y · Male·ischaemic heart disease due to coronary atherosclerosis
A 35-year-old Aboriginal man died of ischaemic heart disease due to coronary atherosclerosis whilst in prison custody. He presented with chest pain and arm tingling at 6:20am but received only Panadol and Mylanta from no…
16y · Male·Peritonitis as a result of ruptured duodenum following blunt trauma of the torso
A 16-year-old boy died from peritonitis secondary to duodenal rupture two days after being treated and discharged from Campbelltown Hospital Emergency Department for a rugby injury. He sustained blunt abdominal trauma fr…
47y · Female·risperidone toxicity
Rosa Sinapi, a 47-year-old woman with delusional disorder, died from risperidone toxicity after ingesting an overdose of her antipsychotic medication. She had self-escalated her risperidone dose from 3mg to 6mg daily wit…
34y · Female·Catastrophic post-partum haemorrhage following caesarean delivery, secondary to …
A 34-year-old Vietnamese woman died from catastrophic postpartum haemorrhage following an elective caesarean delivery. Placenta accreta was discovered intraoperatively and managed with blood transfusion, uterotonic agent…
26y · Male·self-inflicted gunshot wound to the head while suffering severe depression
Morgan Hill, a 26-year-old NSW police officer, died by self-inflicted gunshot wound in March 2009 while severely depressed. Over 20 months prior to death, he experienced escalating mental health difficulties with work ab…
29y · Male·acute bronchopneumonia complicated by multi-drug toxicity
Nicholas Ang, aged 29, with schizoaffective disorder, died from acute bronchopneumonia complicated by multi-drug toxicity while in a psychiatric unit. Admitted 12 August 2005, he was on clozapine, valproic acid, and clon…
78y · Male·Complications of bowel surgery; specifically post-operative chest infection and …
Barry Howroyd, a 78-year-old man, underwent routine colonoscopy on 7 August 2008 which complicated a known bowel carcinoma diagnosis. The procedure caused bowel perforation, diagnosed the next day via CT imaging. Surgica…
50y · Female·compression of the neck consistent with hanging
Yan Yi Xu, a 50-year-old woman with a history of depression and recent breast cancer diagnosis, was admitted to Cramond Clinic psychiatric ward following a suicide attempt on Christmas Day 2008. She died by hanging in he…
21y · Male·Suicide by hanging
A 21-year-old Aboriginal man with schizophrenia and depression died by suicide in prison custody. Key clinical failures included: (1) inadequate mental health assessment by Dr S.—45-minute screening reviewing only one of…
34y · Female·Hanging with combined effects of ethanol and benzodiazepines
Lisa Sharp, 34-year-old woman on a Community Treatment Order for schizophrenia, depression, and anxiety, died by hanging on 16-17 December 2007. She was in severe distress over losing custody of her children, with a cour…
8y · Male·Septic shock consequent on burst appendix with peritonitis
Jacob Belim, aged 8, presented to a GP with appendicitis on 24 March 2009 but the diagnosis was missed. The next day, his treating doctor correctly diagnosed ruptured appendix and referred him urgently to hospital. At Li…
91y · Female·pulmonary thromboembolism and subcutaneous abscess formation complicating pressu…
A 91-year-old woman died from pulmonary thromboembolism and abscess formation complicating untreated ankle fracture and pressure sores. She had sustained a fracture-dislocation of her right ankle after a fall, which she …
63y · Male·cerebral infarction
John Arthur Burns, a 63-year-old man with frontotemporal dementia and motor neurone disease, died from cerebral infarction on 17 September 2006 while in Westminster Aged Care Facility after only 12 days of residence. Des…
Female·Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perfor…
Two elderly women died following vaginal prolapse surgery performed by the same surgeon, Dr O., with similar mechanisms: bowel perforation leading to peritonitis and sepsis. Mrs Leonard (77) underwent laparoscopic surger…
19y · Male·Drowning due to head injury
19-year-old elite surf competitor Saxon Bird died after being struck in the head by an unmanned ski during the 2010 Australian Surf Life Saving Championships at Kurrawa Beach. He lost consciousness and drowned; his body …
64y · Female·Bilateral pulmonary embolism with left middle cerebral artery/posterior cerebral…
Marlene Kenny, 64, presented to Orbost Hospital on 8 January 2007 with chest tightness, breathing difficulties and low oxygen saturation (83-86%). A doctor diagnosed panic attack and discharged her without investigation.…
48y · Female·acute myocarditis resulting from systemic viral infection
A 48-year-old Aboriginal woman with chronic diseases (diabetes, COPD, ischaemic heart disease) presented with ongoing chest infection symptoms across multiple clinic visits between 30 March and 4 April 2010. Despite five…
44y · Male·Cardiomegaly
Lionel Perry, a 44-year-old Aboriginal man with schizoaffective disorder and polysubstance abuse history, died from cardiomegaly (enlarged heart due to concentric ventricular hypertrophy) while an involuntary psychiatric…
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