62 results
54y · Male·Respiratory failure secondary to prolonged ventilation for management of sepsis …
Christopher McIntosh, a 54-year-old man with Type II diabetes and chronic foot ulcers, died from respiratory failure secondary to sepsis arising from an infected foot ulcer requiring above-knee amputation. He was incarce…
41y · Female·multiple stab wounds to the neck
This inquest examined the death of Prabha Arunkumar, a 41-year-old computer programmer who died from multiple stab wounds to the neck sustained during an attack in Parramatta Park on 7 March 2015. She was transported to …
71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation …
A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxon…
40y · Male·Acute hepatic and renal failure in the setting of postoperative haemorrhage foll…
A 40-year-old man with obesity, COPD, diabetes and hypertension died from acute hepatic and renal failure following postoperative haemorrhage after left radical nephrectomy for a 10cm renal cell carcinoma. The surgeon ap…
68y · Male·Cerebrovascular disease
John Raymond Ainsworth, a 68-year-old prisoner, died of cerebrovascular disease following a severe stroke on 25 November 2020. He had poorly controlled Type II diabetes, hypertension, and high cholesterol. Prior to his a…
73y · Male·sepsis due to ischemic gut due to occlusion of the superior mesenteric artery
A 73-year-old man presented with acute severe abdominal pain caused by superior mesenteric artery (SMA) occlusion. Initial CT angiogram at 12:30am was reported as normal; the SMA occlusion was not identified until 4:45am…
87y · Female·Haemorrhage secondary to an ulcerated varicose vein
An 87-year-old woman died from haemorrhage secondary to an ulcerated varicose vein on her right leg. She had known venous insufficiency documented by duplex scan in November 2020, but no specific management plan for blee…
75y · Male·ruptured abdominal aortic aneurysm
A 75-year-old man with hypertension, diabetes, and smoking history presented to a regional emergency department with right lower quadrant abdominal pain, back pain, groin pain, nausea, and vomiting. He was diagnosed with…
83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)
An 83-year-old male prisoner died from complications of a ruptured abdominal aortic aneurysm (AAA) after a 5-month delay in diagnostic confirmation and treatment. An incidental finding of an 8.7 cm AAA was identified on …
80y · Male·Complications of vertebral artery and right carotid artery vascular injuries (op…
An 80-year-old retired surgeon died from complications of vertebral artery and right carotid artery vascular injuries and cervical spine injuries sustained in a body surfing incident at Sandy Gully Beach. He was struck b…
37y · Male·Pulmonary thromboembolus due to left leg deep vein thrombosis
A 37-year-old Aboriginal man died of pulmonary thromboembolism due to deep vein thrombosis while incarcerated. He presented to hospital on his birthday with lethargy, shortness of breath, and tachycardia. Initial assessm…
67y · Female·Intra-abdominal sepsis complicating an anastomotic leak following elective surge…
A 67-year-old woman died from intra-abdominal sepsis following an anastomotic leak from elective colorectal surgery to repair a vesico-colic fistula. The initial surgery on 1 November 2017 was appropriately performed, an…
71y · Male·End-stage chronic obstructive pulmonary disease and atherosclerotic heart diseas…
Colin Albert Winter, a 71-year-old prisoner who died from end-stage COPD and atherosclerotic heart disease, received comprehensive medical care during 33 years of incarceration at Casuarina Prison. Key clinical lessons i…
89y · Male·septicaemia due to infected groin wound, femoropopliteal bypass in a man with mu…
An 89-year-old man with multiple comorbidities (diabetes, peripheral vascular disease, heart failure) developed a groin wound infection following femoropopliteal bypass surgery while residing in aged care. The wound dete…
75y · Male·acute bronchopneumonia in a man with comorbidities
A 75-year-old sentenced prisoner died from acute bronchopneumonia with comorbidities. Mr Rice had extensive medical complexity including COPD, cardiac disease, peripheral vascular disease, and diabetes. He was appropriat…
57y · Female·Combined features of moderately stenosed right coronary ostium, aortic valve reg…
Fiona Lebner, a 57-year-old woman with severe intellectual disability living in a group home, died suddenly from acute cardiac arrhythmia secondary to multiple heart abnormalities including aortic valve disease, mitral v…
41y · Male·haemothorax due to ruptured thoracic aortic aneurysm in a man with Marfan syndro…
A 41-year-old man with Marfan syndrome and a thoracic aortic aneurysm managed conservatively with blood pressure medications died from aneurysm rupture while imprisoned. Methylamphetamine in his system significantly elev…
74y · Female·Complications of carotid artery injury from central line insertion in the settin…
Susan Royals, a 74-year-old woman with metastatic colon cancer, died from complications of carotid artery injury sustained during central venous catheter (CVC) insertion as part of a Whipple procedure and hemicolectomy. …
41y · Male·heart failure related to exsanguination due to traumatic rupture of an arteriove…
Nicholas Summers, a 41-year-old kidney transplant recipient, died from traumatic rupture of an arteriovenous fistula with massive hemorrhage on 16 February 2016. He had returned to Tasmania under nephrologist Dr Mathew's…
68y · Male·Complications following myocardial infarction and its treatment in a man with mu…
Salvatore Otranto, a 68-year-old prisoner with multiple severe comorbidities including ischaemic heart disease, diabetes, COPD, and chronic kidney disease, died from complications of myocardial infarction and its treatme…
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