29 results
83y · Male·Congestive cardiac failure due to ischaemic and valvular heart disease, with her…
Frank Valentine, an 83-year-old man, died from congestive cardiac failure due to ischaemic and valvular heart disease, with hereditary haemorrhagic telangiectasia (HHT) and anaemia as contributory conditions. He was serv…
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…
53y · Male·Metastatic pancreatic carcinoma
Michael Sanderson, a 53-year-old Gamilaroi man, died from metastatic pancreatic cancer while in custody. Critical clinical lessons emerge: (1) failure to review pathology results within required 14-day timeframe delayed …
41y · Male·Septicaemia secondary to chronic peptic ulcer disease
Simon Cartwright, a 41-year-old man with schizophrenia and bipolar disorder, died in custody from septicemia secondary to chronic peptic ulcer disease. He had a documented ulcer history diagnosed in November 2020 and sho…
36y · Male·perforated duodenal ulcer
Ricky Douglas Hampson, a 36-year-old First Nations man, presented to Dubbo Base Hospital on 14 August 2021 with sudden onset severe abdominal pain and a reported sensation of something popping in his abdomen. He had two …
48y · Female·Ischaemic bowel, with contributing conditions of coronary artery disease, diabet…
Ms Vicki Higgins, a 48-year-old woman with diabetes, Crohn's disease (requiring ileostomy), and coronary artery disease, died from ischaemic bowel while in custody at Junee Correctional Centre on 29 January 2022, only 17…
48y · Female·Ischaemic bowel; coronary artery disease, diabetes mellitus and Crohn's disease …
Ms Vicki Higgins, a 48-year-old woman with diabetes, Crohn's disease (with prior colectomy and ileostomy), and coronary artery disease, died from ischaemic bowel on day 17 of incarceration at Junee Correctional Centre du…
44y · Male·multiple injuries from fall from cliff
A 44-year-old man with familial Mediterranean fever (FMF) and bipolar affective disorder with drug-induced psychosis died following a fall from a cliff at Vaucluse during a police rescue operation. He had been managing s…
76y · Male·small bowel obstruction in the setting of terminal metastatic neuro-endocrine tu…
A 76-year-old Aboriginal man died of small bowel obstruction from metastatic neuro-endocrine tumour after spending nearly two years requesting medical help in prison without receiving a doctor's review. Between October 2…
44y · Male·cardiogenic shock, on a background of severe tricuspid valve regurgitation, seve…
Jeffrey Blundell, a 44-year-old man with severe intravenous drug use history, died from cardiogenic shock secondary to severe tricuspid valve regurgitation caused by infective endocarditis from non-sterile injection prac…
59y · Male·complications of viral liver cirrhosis with hepatocellular carcinoma
Mervyn Morgan, aged 59, died from complications of hepatocellular carcinoma arising from cirrhosis while in prison custody. Critical failures included: delayed monitoring of known liver cirrhosis (no ultrasound despite M…
60y · Male·metastatic atrial sarcomatoid tumour
Steve Fesus, aged 60, died in custody at Prince of Wales Hospital from metastatic atrial sarcomatoid tumour. He had been diagnosed with cardiac cancer in 2016, underwent surgery, and was in remission until metastases wer…
64y · Male·Consequences of metastatic oesophageal carcinoma with Stanford B dissection thor…
Jose Manuel Xavier, a 64-year-old prisoner, died from metastatic oesophageal carcinoma with a contributing Stanford B thoracic aortic dissection. He was diagnosed with oesophageal cancer in July 2019 after presenting wit…
74y · Male·metastatic gastro-oesophageal adenocarcinoma
Ivan Milat, aged 74, died of metastatic gastro-oesophageal adenocarcinoma whilst in lawful custody at Long Bay Correctional Centre. He presented with gastrointestinal symptoms from October 2018, was initially treated for…
3y · Male·respiratory failure, with spinal muscular atrophy an antecedent cause
Tory Ganderton, a 3-year-old boy with spinal muscular atrophy (SMA) Type 1, died of respiratory failure during inter-hospital transfer. Admitted to Shoalhaven Hospital on 7 September 2014 with pneumonia and severe malnut…
61y · Female·multi organ failure due to abdominal sepsis
Lesley Arndell, aged 61, died from multi-organ failure due to abdominal sepsis after undergoing a Whipple's procedure for pancreatic cancer. Key clinical lessons include: (1) patients with previous bariatric surgery requ…
84y · Male·staphylococcus aureus sepsis complicating metastatic malignancy
Douglas Anderson, aged 84, died of staphylococcus aureus sepsis complicating metastatic malignancy (gastro-oesophageal origin) while in custody at Westmead Hospital, nine days after arrest. The coroner found his death wa…
33y · Female·Hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiop…
Melissa King, aged 33, died from hypoxic ischaemic encephalopathy following in-hospital cardiopulmonary arrest at Blacktown Hospital. She presented with severe malnutrition, electrolyte derangements including hyponatraem…
49y · Male·Complications of metastatic gastric adenocarcinoma
Ahmed Rizk, a 49-year-old man in custody, died from complications of metastatic gastric adenocarcinoma. He presented with abdominal pain and constipation on 10 August 2017, was investigated at Glen Inness District Hospit…
52y · Male·Intestinal failure/sepsis arising from venous ischemia as a result of superior m…
Patrick Thomas, a 52-year-old man, died from intestinal failure and sepsis following an accidental division of the superior mesenteric vein (SMV) during laparoscopic surgery for colon cancer at Kareena Private Hospital o…
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