6 results
61y · Male·end stage renal failure, in the context of type 2 diabetes mellitus and chronic …
Robert Curtis, a 61-year-old Aboriginal man with end-stage renal disease, end-stage liver disease, and poorly controlled diabetes, was imprisoned for driving while disqualified on 4 February 2019. He fell in the prison s…
51y · Male·Multiple organ failure due to Influenza A pneumonia, in the context of chronic k…
Ishmael Nalaiyir Nangarid, a 51-year-old Aboriginal man with complex medical history including myasthenia gravis, chronic kidney disease, COPD, and ischaemic heart disease, died from multiple organ failure due to Influen…
46y · Female·Cardiac arrest of unknown origin
Virginia Brown, a 46-year-old Aboriginal woman, died of cardiac arrest of unknown origin on 31 October 2014 while detained under a Mandatory Residential Treatment (MRT) order at CAAAPU (Central Australian Aboriginal Alco…
50y · Male·myocardial infarction caused by coronary atherosclerosis
Desmond Jambajimba Tilmouth, a 50-year-old Aboriginal man, died of myocardial infarction from severe coronary atherosclerosis complicated by end-stage renal disease and an incarcerated strangulated umbilical hernia. He d…
67y · Male·acute renal failure with associated severe acidosis and hyperkalemia
A 67-year-old Aboriginal male with dementia was discharged from Royal Darwin Hospital on 4 November 2001 following cystoscopy and bladder neck incision for suspected obstruction. Critical communication failures meant the…
74y · Male·disseminated carcinoma (widespread cancer); specifically haemorrhage into right …
Ronald Smallwood, a 74-year-old man with chronic paranoid schizophrenia and renal cancer, died in hospital from disseminated carcinoma. The key clinical lesson relates to institutional knowledge rather than direct patien…
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