3,729 results
50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…
Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…
89y · Male·combination of biochemical consequences of colonic pseudo-obstruction and faecal…
An 89-year-old man with multiple comorbidities including previous colon cancer died from faecal impaction and stercoral colitis. He resided in a residential aged care facility (RACF) where staff failed to recognize that …
Unknown·Toxicity to protonitazene
Four adults died on 24 June 2024 from protonitazene toxicity after ingesting illicitly purchased drugs they believed to be MDMA and cocaine. Protonitazene is a novel synthetic opioid approximately 100 times more potent t…
Toxicity to protonitazene
Four adults died on 24 June 2024 following inhalation of cocaine adulterated with protonitazene, a novel synthetic opioid 100 times more potent than heroin. Michael Hodgkinson purchased drugs believed to be MDMA and coca…
Unknown·Toxicity to protonitazene
Four adults died on 24 June 2024 from protonitazene toxicity after purchasing drugs believed to be MDMA and cocaine in Melbourne. Protonitazene is a novel synthetic opioid 100 times more potent than heroin that has conta…
62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…
A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…
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…
47y · Male·Compression of the neck arising from hanging
47-year-old man with antisocial personality disorder, psychosis, and methamphetamine use died by hanging. He presented to emergency departments on 10, 19, and 20 September 2021 with suicidal ideation, auditory hallucinat…
53y · Male·Metastatic pancreatic carcinoma
Michael Sanderson, a 53-year-old Gamilaroi man, died from metastatic pancreatic cancer while in custody. Critical clinical lessons emerge: (1) failure to review pathology results within required 14-day timeframe delayed …
35y · Male·Neck compression due to hanging
Joshua Gonzalez, 35, died by suicide on 5 September 2020 after being discharged from Footscray Hospital. He had been apprehended by police under section 351 of the Mental Health Act after threatening self-harm and asking…
38y · Female·end stage renal failure (Stage 5 chronic kidney disease)
Ms Harwood, a 38-year-old transgender woman with end-stage renal disease, died of natural causes following refusal of dialysis. Her mother claimed the death was suicide prompted by fear of returning to prison following a…
32y · Female·mixed drug toxicity including phenobarbitone
A 32-year-old woman with borderline personality disorder and depression died by intentional self-administration of pentobarbitone (Lethabarb) accessed from her workplace. She had experienced extensive family violence in …
64y · Male·Complications of congestive cardiac failure on a background of cardiac hypertrop…
QBT, a 64-year-old man with complex medical and psychiatric history including schizophrenia, COPD, and hypertension, was admitted to Bendigo Hospital on an Assessment Order after police concerns about mental health deter…
46y · Male·Aspiration pneumonia complicating epistaxis in the setting of prolonged nasal pr…
Hau Bui Nguyen, a 46-year-old man with severe acquired brain injury, dysphagia, and recurrent aspiration pneumonia, died from aspiration pneumonia complicating epistaxis following prolonged nasal prong oxygen therapy. Du…
41y · Female·complications of intracerebral haemorrhage due to ruptured aneurysm
Dannielle Stacey Lowe, a 41-year-old Aboriginal woman, died in custody at Wandoo Rehabilitation Prison from complications of intracerebral haemorrhage due to a ruptured cerebral aneurysm. Critical missed opportunities in…
69y · Male·thoracic aortic aneurysm with dissection
Peter Hanisch, a 69-year-old man, died from thoracic aortic aneurysm with dissection on 22 August 2021. He presented to Calvary Hospital on 19 August 2021 with sudden chest discomfort and neurological symptoms. A CT angi…
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…
0y · Male·Unascertained in the setting of a remote head injury
Child A, a six-month-old Aboriginal boy, died from unascertained cause in the setting of a remote head injury sustained during family violence. The father violently assaulted the mother while holding the child unsupporte…
7y · Female·Group A Streptococcus (Streptococcus pyogenes) pneumonia with sepsis
A 7-year-old previously healthy girl died from Group A Streptococcus pneumonia with sepsis after paramedics failed to transport her to hospital despite recording a severely elevated heart rate (172 and 168 bpm) on 15 Sep…
81y · Male·Community acquired pneumonia in a man with acute on chronic renal failure
An 81-year-old man with chronic respiratory disease and renal failure died from community-acquired pneumonia complicated by acute-on-chronic renal failure. He presented to hospital on 25 April 2023 with respiratory failu…
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