96 results
54y · Male·Respiratory failure secondary to prolonged ventilation for the management of sep…
Christopher McIntosh, a 54-year-old man with type 2 diabetes, died from respiratory failure secondary to sepsis originating from an infected foot ulcer while incarcerated at Hopkins Correctional Centre. The coroner found…
54y · Male·Respiratory failure secondary to prolonged ventilation for management of sepsis …
Christopher McIntosh, a 54-year-old man with Type II diabetes and chronic foot ulcers, died from respiratory failure secondary to sepsis arising from an infected foot ulcer requiring above-knee amputation. He was incarce…
79y · Male·Complications of peripheral vascular disease with Type 2 Diabetes Mellitus, atri…
John Reginald Wright, a 79-year-old remand prisoner, died from complications of peripheral vascular disease with diabetes, atrial fibrillation, cardiomyopathy and delirium. He was transferred to Princess Alexandra Hospit…
41y · Female·multiple stab wounds to the neck
This inquest examined the death of Prabha Arunkumar, a 41-year-old computer programmer who died from multiple stab wounds to the neck sustained during an attack in Parramatta Park on 7 March 2015. She was transported to …
71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation …
A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxon…
93y · Female·acute right lower limb ischaemia
Adelina Zito, a 93-year-old resident of an aged care facility, died from acute limb ischaemia after a 6-7 day delay in escalating her care. She developed right leg pain around 26-28 July 2022 that worsened despite parace…
84y · Male·haemoperitoneum due to ruptured abdominal aortic aneurysm
Bernard Greenwell, an 84-year-old male, died from rupture of an abdominal aortic aneurysm (AAA) while in custody at Cessnock Correctional Centre. He experienced sudden-onset severe left groin pain at 11:30am on 25 April …
40y · Male·Acute hepatic and renal failure in the setting of postoperative haemorrhage foll…
A 40-year-old man with obesity, COPD, diabetes and hypertension died from acute hepatic and renal failure following postoperative haemorrhage after left radical nephrectomy for a 10cm renal cell carcinoma. The surgeon ap…
68y · Male·Cerebrovascular disease
John Raymond Ainsworth, a 68-year-old prisoner, died of cerebrovascular disease following a severe stroke on 25 November 2020. He had poorly controlled Type II diabetes, hypertension, and high cholesterol. Prior to his a…
73y · Male·sepsis due to ischemic gut due to occlusion of the superior mesenteric artery
A 73-year-old man presented with acute severe abdominal pain caused by superior mesenteric artery (SMA) occlusion. Initial CT angiogram at 12:30am was reported as normal; the SMA occlusion was not identified until 4:45am…
87y · Female·Haemorrhage secondary to an ulcerated varicose vein
An 87-year-old woman died from haemorrhage secondary to an ulcerated varicose vein on her right leg. She had known venous insufficiency documented by duplex scan in November 2020, but no specific management plan for blee…
75y · Male·ruptured abdominal aortic aneurysm
A 75-year-old man with hypertension, diabetes, and smoking history presented to a regional emergency department with right lower quadrant abdominal pain, back pain, groin pain, nausea, and vomiting. He was diagnosed with…
74y · Female·Cardiac arrest due to pulmonary embolism secondary to deep venous thrombosis
A 74-year-old woman presented to ED with left leg swelling and calf pain. She was triaged as category 4 and seen by a doctor after a 4-hour 24-minute delay due to staff shortages and access block. A D-Dimer test showed e…
83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)
An 83-year-old male prisoner died from complications of a ruptured abdominal aortic aneurysm (AAA) after a 5-month delay in diagnostic confirmation and treatment. An incidental finding of an 8.7 cm AAA was identified on …
80y · Male·Complications of vertebral artery and right carotid artery vascular injuries (op…
An 80-year-old retired surgeon died from complications of vertebral artery and right carotid artery vascular injuries and cervical spine injuries sustained in a body surfing incident at Sandy Gully Beach. He was struck b…
70y · Male·Hemopericardium due to ruptured aortic dissection contributed to by hypertension
Mr James Brown, a 70-year-old prisoner with a long-standing history of hypertension and atrial fibrillation, died from hemopericardium due to ruptured aortic dissection. He collapsed with chest pain while at work in the …
37y · Male·Pulmonary thromboembolus due to left leg deep vein thrombosis
A 37-year-old Aboriginal man died of pulmonary thromboembolism due to deep vein thrombosis while incarcerated. He presented to hospital on his birthday with lethargy, shortness of breath, and tachycardia. Initial assessm…
67y · Female·Intra-abdominal sepsis complicating an anastomotic leak following elective surge…
A 67-year-old woman died from intra-abdominal sepsis following an anastomotic leak from elective colorectal surgery to repair a vesico-colic fistula. The initial surgery on 1 November 2017 was appropriately performed, an…
45y · Male·Haemorrhagic transformation of cerebral infarction, due to bilateral internal ca…
David Smith, aged 45, died from haemorrhagic transformation of cerebral infarction secondary to essential thrombocytosis with bilateral internal carotid artery thrombosis. He developed an acute ischaemic stroke on 9 July…
71y · Male·End-stage chronic obstructive pulmonary disease and atherosclerotic heart diseas…
Colin Albert Winter, a 71-year-old prisoner who died from end-stage COPD and atherosclerotic heart disease, received comprehensive medical care during 33 years of incarceration at Casuarina Prison. Key clinical lessons i…
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