12 results
69y · Male·peritonitis due to perforated bowel
Mr Deleman was a 69-year-old man with untreated schizophrenia, advanced liver cirrhosis, and hepatitis C, presenting to hospital on 1 April 2024 with abdominal swelling. He was admitted to The Canberra Hospital and place…
67y · Female·ischaemic heart disease
Merren Elizabeth Bartley, a 67-year-old woman with schizophrenia managed with clozapine and multiple comorbidities including coronary artery disease, died of ischaemic heart disease while an inpatient at a mental health …
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
Maarouf El-Cheikh, a 57-year-old man with splenectomy history, presented to Calvary Hospital ED with sepsis on 21 March 2016 and died 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadeq…
72y · Female·subdural haemorrhage sustained from a fall from a hospital bed on 18 January 201…
Mrs Judith Gaye Flynn, aged 72, died from a subdural haemorrhage sustained when she fell from a hospital bed on the General Medicine Ward at Canberra Hospital. She was a high-risk fall patient with cognitive impairment, …
83y · Female·pneumonia with generalised atherosclerosis as a significant contributor
Pamela Vance, 83, died from pneumonia with generalised atherosclerosis as a significant contributor. She had multiple comorbidities including COPD, asthma, sleep apnoea and heart disease, complicated by recent falls and …
54y · Female·Multiple organ failure, due to pneumonia in a patient with Guillain-Barré syndro…
Julie Ann Hermans, a 54-year-old Aboriginal woman with Guillain-Barré syndrome, quadriplegia, diabetes, and recurrent infections, died from multiple organ failure due to hospital-acquired pneumonia during an ICU admissio…
72y · Male·Haemopericardium due to anti-coagulation treatment for pulmonary thromboemboliti…
Jeffrey Brown, a 72-year-old with recent cardiac surgery (CABG), died from haemopericardium due to anticoagulation treatment for pulmonary thromboembolism. Post-mortem examination revealed fibrinous pericarditis (a known…
61y · Male·exposure and dehydration, preceded by alcohol withdrawal and chronic alcoholism
A 61-year-old man with chronic alcoholism was admitted to hospital for alcohol withdrawal management. He became confused and paranoid on the ward, received appropriate medication, but left hospital unobserved approximate…
32y · Female·massive postpartum intracerebral haemorrhage of spontaneous hypertensive origin
A 32-year-old woman with Factor V Leiden mutation died from a massive postpartum intracerebral haemorrhage of hypertensive origin five hours after delivering twins. She had been diagnosed with pregnancy-induced hypertens…
69y · Male·asphyxia by hanging
A 69-year-old man with depression, prostate cancer, and recent suicide attempt was admitted to MAPU (general medical ward) after intensive care treatment. He was deemed low suicide risk and the one-on-one attendant was d…
Female·retroperitoneal blood loss in a setting of anticoagulation therapy following hip…
Valerie Kolts died from retroperitoneal blood loss following hip replacement surgery while on anticoagulation therapy. The coroner found no lack of care contributed to her death. Although some clinical signs were retrosp…
Female·bilateral acute bronchopneumonia
Ivy Pearl Ghobrial died from bilateral acute bronchopneumonia at a nursing home in September 2001, following a hypoxic brain injury sustained from a hanging attempt in March 2000. The coroner found the death resulted ine…
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