167 results
41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…
Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…
60y · Male·Pulmonary tuberculosis in a man with chronic obstructive pulmonary disease, with…
David John Hatcher, aged 60, was a remand prisoner at Hakea who died at Fiona Stanley Hospital on 27 September 2024 from pulmonary tuberculosis superimposed on severe chronic obstructive pulmonary disease. He was hospita…
1y · Male·Complications of acute lymphoblastic leukaemia
Sandipan Dhar, 21 months old, died from undiagnosed acute lymphoblastic leukaemia (ALL) complicated by sepsis and pneumonia on 24 March 2024. After three weeks of intermittent fever, he attended his GP three times and wa…
Male·out-of-hospital cardiac arrest due to atherosclerotic cardiovascular disease and…
Lewis Walter Ward, a Ngarinyin man in his early thirties, died from out-of-hospital cardiac arrest while playing sport at West Kimberley Regional Prison. He had Type 2 diabetes, hypertension, dyslipidaemia, and was a smo…
30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…
Karl Steinhauser, a 30-year-old man with schizoaffective disorder and polysubstance misuse, died from pulmonary thromboembolism on 12 March 2023 while under Mental Health Act care. After two weeks of increasingly challen…
16y · Male·complications of ligature compression of the neck (hanging)
A 16-year-old Aboriginal youth, Cleveland Keith Dodd, died by suicide via hanging in Unit 18, a youth detention centre housed within an adult maximum-security prison in Western Australia. The coroner found Cleveland's de…
21y · Male·unascertained
Samaan Salah Tilmiz Elsamin, a 21-year-old with treatment-resistant schizophrenia, moderate-to-severe intellectual disability (IQ 57), and unpredictable violent behavior, died on 9 November 2022 at Joondalup Health Campu…
48y · Female·intracerebral haemorrhage on a background of anticoagulation therapy for a recen…
Monique Gomez, 48, died from a spontaneous intracerebral haemorrhage during hospitalization for stroke rehabilitation and treatment of schizoaffective disorder. An initial ischaemic stroke resulted from non-compliance wi…
69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…
Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…
51y · Male·complications of myocardial infarction in association with ischaemic heart disea…
A 51-year-old Aboriginal male prisoner with multiple cardiovascular risk factors (diabetes, hypertension, high cholesterol, chronic kidney disease, obesity, smoking) died on 5 February 2024 from myocardial infarction. He…
31y · Female·organ failure due to anorexia nervosa
Chloe Tupper died of organ failure due to severe anorexia nervosa at age 31. She had suffered from this illness for 17 years since age 14, receiving multiple episodes of hospital-based refeeding that never achieved lasti…
49y · Male·combined drug toxicity
Karl Turner, a 49-year-old man with schizoaffective disorder and chronic polysubstance use, died from combined drug toxicity (heroin, morphine, pregabalin, methylamphetamine, and cannabis). He was managed on a Community …
36y · Male·ligature compression of the neck (hanging)
A 36-year-old man with schizoaffective disorder, traumatic brain injury, and substance use disorder died by ligature while an involuntary inpatient in a locked mental health ward. He was on hourly observations and had re…
41y · Male·complications in association with effects of fire, with terminal palliative care
Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by suicide on 1 November 2021 after self-immolating with boat f…
46y · Male·head injury complicated by bronchopneumonia, with palliation
A 46-year-old remand prisoner died from traumatic brain injury sustained during a severe prison assault. Critical failures in responding to cell call alarms preceded the attack. Prison officers answered multiple distress…
65y · Male·complications, including pneumonia, of traumatic brain injury
A 65-year-old male prisoner died from complications of severe traumatic brain injury sustained when punched by another prisoner at Hakea Prison. He fell backwards, striking his head, and was assessed at the prison medica…
46y · Male·sepsis following haemorrhoidectomy
46-year-old Justin Mark Dobson died from sepsis following a routine haemorrhoidectomy on 17 July 2019. He was discharged to the ward overnight but deteriorated significantly from 11:00 am on 18 July, showing hypotension,…
26y · Female·meningococcal infection (Neisseria meningitidis W strain) causing septicaemia
Ashleigh Rebecca Hunter, a previously healthy 26-year-old, died from meningococcal septicaemia (W strain) within 3 hours of arriving at Royal Perth Hospital. She presented with severe generalised pain (10/10), tachycardi…
2y · Male·multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndro…
A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poo…
Male·Gunshot injury to the head
Matthew Worthington died from a self-inflicted gunshot wound to the head during a 21-hour police siege at his home in Bayswater, Western Australia, on 24 November 2020. He was experiencing a relationship breakdown, had r…
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