58y · Male·complications of oesophageal cancer, with terminal palliative care
Stephen Joseph Schipp, a 58-year-old sentenced prisoner, died from complications of oesophageal cancer with terminal palliative care at Bunbury Regional Hospital. He had been diagnosed with oesophageal carcinoma in Janua…
44y · Female·Cardiac arrest in the context of several contributory factors (physical exertion…
Selesa Tafaifa, a 44-year-old woman with Samoan heritage, died in custody at Townsville Women's Correctional Centre on 30 November 2021 during physical restraint by correctional officers, including application of a safet…
90y · Female·Right acute on chronic subdural haematoma sustained in a fall in the setting of …
A 90-year-old woman on warfarin for atrial fibrillation suffered an unwitnessed fall with head strike at an aged care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT …
43y · Male·methadone toxicity
Frank Coleman, a 43-year-old First Nations man, died of methadone toxicity after being supplied diverted methadone by another inmate while imprisoned at Long Bay Correctional Complex. Mr Coleman had repeatedly requested …
65y · Male·Ischaemic heart disease on a background of hypertension
John Kennedy, 65, died from ischaemic heart disease with hypertension on 16 April 2020 after a 24-minute delay in ambulance dispatch. He called triple zero at 00:19 with severe chest pain and difficulty breathing (Priori…
55y · Male·Acute myocardial infarction secondary to coronary artery thrombosis due to coron…
Anthony Creaton, 55, died of acute myocardial infarction due to coronary artery thrombosis and atherosclerosis in prison custody. He presented with chest pain on 13 November 2022 (twice) and again on 14 November, but nur…
55y · Male·Complications of alcohol use disorder
Dushyanthan Visvanathan, a 55-year-old man with alcohol use disorder and prior withdrawal seizure, died in custody at MRRC from complications of alcohol use disorder. Critical failures in clinical care included: inadequa…
28y · Male·Cardiac arrhythmia
Lathan Brown, a 28-year-old Aboriginal man, died of cardiac arrhythmia while in custody at Wellington Correctional Centre on 6 January 2024. He suffered sudden cardiac arrest in his cell; emergency response was appropria…
Unknown·Panella: pulmonary thromboembolism due to left calf deep vein thrombosis; Skeffi…
Three South Australians died following extended waits on ambulance ramps outside metropolitan hospitals. Anna Panella (76) died from pulmonary thromboembolism; Bernard Skeffington (89) died from aspiration pneumonia afte…
30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…
Heather Calgaret, a 30-year-old Aboriginal woman, died from hypoxic ischaemic encephalopathy after being administered a first dose of buprenorphine (Buvidal) injection without prior stabilisation on sublingual Suboxone. …
53y · Female·Unascertained
A 53-year-old woman died after consuming psilocybin-containing mushrooms at an unlicensed retreat. She consumed approximately 6 grams of mushroom powder brewed as tea, became unable to walk, reported breathing difficulti…
60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…
James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…
79y · Female·Dilated cardiomyopathy with decompensated heart failure not appropriately treate…
A 79-year-old woman with severe COPD and heart failure presented with two weeks of nausea and vomiting. She was diagnosed with left ventricular failure (EF 33%) on day 1 of admission. Two cardiologists had key roles: Dr …
75y · Female·Ischaemic heart disease in the setting of unstable type 2 diabetes mellitus and …
Veronica Roberts, 75, died from ischaemic heart disease complicated by unstable diabetes and a medication error. On 4 October 2020, her insulin dose was increased to 20 units daily, but due to Electronic Medical Record (…
94y · Female·Complications of a fractured neck of femur sustained in an unwitnessed in-hospit…
A 94-year-old woman with significant cardiopulmonary comorbidities died from complications of a fractured femur sustained in an unwitnessed hospital fall. Despite identification as high falls risk and implementation of f…
41y · Female·Cardiomegaly
Jessica Katgert, aged 41, died in custody at Dame Phyllis Frost Centre from cardiomegaly. She had a history of MSSA infective endocarditis treated in 2021 with echocardiographic changes including dilated left ventricle a…
69y · Male·thoracic aortic aneurysm with dissection
Peter Hanisch, a 69-year-old man, died from thoracic aortic aneurysm with dissection on 22 August 2021. He presented to Calvary Hospital on 19 August 2021 with sudden chest discomfort and neurological symptoms. A CT angi…
67y · Male·Intracranial haemorrhage complicating coronary artery bypass graft surgery follo…
A 67-year-old man died from intracranial haemorrhage following coronary artery bypass graft surgery. He had suffered a right coronary artery dissection during percutaneous coronary intervention at Sunshine Hospital and w…
62y · Male·cardiac arrhythmia secondary to prolongation of the QT interval
NL, a 62-year-old man with schizoaffective disorder and hypothyroidism, died of cardiac arrhythmia secondary to QT prolongation while an involuntary mental health inpatient. He had a known history of non-compliance with …
45y · Male·atherosclerotic heart disease
Lex Gregory Maher, a 45-year-old Aboriginal man imprisoned at Greenough Regional Prison, died of atherosclerotic heart disease while playing basketball. He had abnormal ECGs detected in March and May 2022 and was appropr…
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