44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…
Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…
50y · Male·unascertained
Simon Gaskill, aged 50, was found deceased in sand dunes at Ocean Grove Beach in April 2022 after sleeping rough for months. He had been discharged from hospital in December 2021 following treatment for severe alcohol wi…
53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures
Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…
70y · Male·Metastatic melanoma with ischaemic heart disease as a contributing condition
Francis Michael Fahey, a 70-year-old prisoner, died from metastatic melanoma with contributing ischaemic heart disease. He presented with a rapidly enlarging axillary mass in February 2023, confirmed as metastatic melano…
Male·Hemant Chadha: acute on chronic pneumonia (mycoplasma pneumoniae). Sachintha Bat…
Two young men died after repeated ED presentations were not appropriately managed. Hemant Chadha (38) died of acute pneumonia complicated by possible neurological involvement after being discharged from Lyell McEwin Hosp…
69y · Male·Pericarditis
A 69-year-old man with a history of atrial fibrillation, chronic kidney disease, congestive cardiac failure, and Fragile X Syndrome presented to the Emergency Department with dyspnea following an unwitnessed fall. He was…
69y · Male·advanced cholangiocarcinoma
Mr Lifa Faafete, aged 69, died from advanced cholangiocarcinoma while in remand custody at Metropolitan Special Programs Centre. He was appropriately transferred to Prince of Wales Hospital on 22 March 2025 for symptom m…
39y · Female·Respiratory failure in the setting of aspiration pneumonia in a woman with arthr…
Nicole Kateiva, a 39-year-old woman with arthrogryposis multiplex congenita, intellectual impairment, and epilepsy, died from respiratory failure due to aspiration pneumonia. She presented to hospital with two days of co…
90y · Male·Ischaemic and valvular heart disease
Gerald Ridsdale, a 90-year-old man incarcerated at Port Phillip Prison, died from ischaemic and valvular heart disease following a period of palliative care. He had multiple chronic conditions including congestive cardia…
53y · Female·Metastatic breast cancer
Nicole Buckley, a 53-year-old Wurundjeri woman with complex medical needs including Dandy-Walker syndrome, intellectual disability, and metastatic breast cancer, died of her malignancy at Sunshine Hospital. She was admit…
78y · Male·Acute pancreatitis
A 78-year-old man with a long history of mental illness and multiple chronic physical conditions died from acute pancreatitis on 12 May 2025, nine days after presenting with nausea and vomiting at Thomas Embling Hospital…
65y · Male·Acute on chronic subdural haematoma caused by accidental falls
Steven Basil Bradley, 65, died from acute on chronic subdural haematoma following an unwitnessed fall in hospital. He had metastatic prostate cancer, ischaemic heart disease, and diabetes. On admission for chest sepsis, …
55y · Female·Combined effects of influenza A infection, acute kidney injury, and aspiration p…
Lani-Kay Illsley, a 55-year-old woman with Rett syndrome residing in specialist disability accommodation, died from combined effects of influenza A infection, acute kidney injury, and aspiration pneumonia. She was admitt…
44y · Male·Sepsis due to Streptococcus pyogenes (Group A Streptococcus) septicaemia complic…
Brian Dean, a 44-year-old with obesity, presented to hospital on 1 July 2023 with influenza A and signs of shock (tachycardia, hypotension, elevated lactate). He was treated with fluids and discharged the next morning ap…
75y · Male·metastatic pancreatic cancer
A 75-year-old man died from metastatic pancreatic cancer while in lawful custody. He was diagnosed in February 2025 and underwent palliative chemotherapy at Prince of Wales Hospital from March-April 2025. He developed an…
88y · Female·Acute on chronic renal failure due to dehydration on a background of Lewy body d…
An 88-year-old woman with Lewy body dementia, Parkinson's disease and congestive cardiac failure died from acute kidney injury precipitated by severe dehydration in aged care. June 2020 blood tests showed mild hypernatra…
57y · Male·Complications of Down syndrome
Brian Leslie Aldridge, a 57-year-old man with Down syndrome, cerebral palsy, intellectual disability and Alzheimer's dementia, died of natural causes in specialist disability accommodation. He experienced declining healt…
72y · Female·acute on chronic renal failure due to sepsis and chronic left leg cellulitis
Kerrie Dawn Grant, a 72-year-old woman with multiple comorbidities including pulmonary hypertension, cardiac failure, COPD, and myelofibrosis, had a well-documented history of recurrent falls with prolonged periods unabl…
52y · Male·Pulmonary thromboembolism
A 52-year-old man with autism, intellectual disability, and multiple comorbidities died from pulmonary thromboembolism at home. He developed respiratory symptoms on 24 March, was managed in primary care with telehealth a…
39y · Female·Undifferentiated large right pleural effusion
Lydia Christopherson, a 39-year-old woman with cerebral palsy, intellectual disability, and epilepsy living in supported accommodation, died from a large right pleural effusion complicated by chest infection. She present…
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