40y · Male·respiratory failure due to Adult Respiratory Distress Syndrome (ARDS)
…ions to antipsychotic medications, was admitted to Royal Adelaide Hospital from psychiatric detention for anaemia requiring blood transfusion. He became agitated during transfusion. An inexperienced intern prescribed ha…
83y · Female·Acute on chronic renal failure secondary to infectious exacerbation of chronic o…
An 83-year-old woman with chronic obstructive pulmonary disease and chronic renal failure died from acute-on-chronic renal failure complica…
75y · Female·multiple organ failure due to severe anaemia secondary to blood loss post electi…
A 75-year-old woman died from multiple organ failure due to severe anaemia after elective hysterectomy surgery. Critical failures occurred: the surgical and anaesthetic teams held …
77y · Male·Complications of chronic obstructive airways disease and ischaemic heart disease
John Paul Barnett, a 77-year-old prisoner with complex medical history including COPD, ischaemic heart disease, cardiomyopathy, and recently diagnosed diffuse large B-cell lymphoma, died at St Vincent's Hospital on Chris…
64y · Male·bronchopneumonia in a man receiving palliative care for terminal cancer of the r…
Bill Portelli, a 64-year-old man with chronic paranoid schizophrenia and terminal rectum cancer with liver metastases, died of bronchopneumonia (from a…
75y · Female·postoperative delirium/exacerbation of community acquired pneumonia following le…
A 75-year-old woman with chronic kidney disease, anemia, and significant mobility impairment fell in her aged care facility despite docume…
76y · Male·end-stage renal failure
…died of end-stage renal failure while imprisoned. He had pre-existing hypertension, diabetes, and stage 3 chronic kidney disease. During his final year in custody, he experienced acute kidney injury superimposed on chro…
60y · Male·end stage refractory chronic congestive cardiac failure on a background of chron…
A 60-year-old man with chronic schizophrenia, end-stage cardiac failure, renal failure, and dementia died of refractory congestive heart…
56y · Male·bronchopneumonia complicated by multiorgan failure and hypoxic ischaemic encepha…
Michael Dyball, a 56-year-old prisoner with chronic kidney disease, hepatitis C, and treated oropharyngeal squamous cell carcinoma, collapsed in his prison c…
85y · Male·Incised wounds to the wrist
…liative and aged care patients. Clinical lessons include: recognising suicide risk in older patients with chronic pain and functional decline; ensuring adequate psychosocial assessment alongside pain management; maintai…
66y · Male·acute myocardial infarction on a background of atherosclerotic cardiovascular di…
…nce May 2007 with a complex medical history including previous bypass surgery, multiple stent insertions, chronic renal failure, type-2 diabetes, and COPD. Days before his death, he was hospitalised for investigation of…
47y · Female·Aspiration pneumonia in the setting of type 1 diabetes mellitus, previous cerebr…
A 47-year-old NDIS participant with a history of stroke, diabetes, and complex comorbidities died from aspiration pneumonia at Austin Hospital. She had been living in specialist disability accommodation with support serv…
91y · Male·ischaemic and hypertensive heart disease
Giovanni Catino, aged 91, died of ischaemic and hypertensive heart disease while detained under a Mental Health Act inpatient treatment order at Repatriation General Hospital. He had advanced Alzheimer's dementia with be…
63y · Male·metastatic carcinoma of the lung (small cell neuroendocrine carcinoma with poorl…
A 63-year-old male prisoner died from metastatic small cell lung cancer with adenocarcinoma features. Cancer was incidentally discovered during investigation of a deep vein thrombosis in October 2018, leading to one mont…
55y · Male·Cardiopulmonary arrest, respiratory failure and chronic obstructive airways dise…
…d, a 55-year-old man with extensive psychiatric history (schizoaffective disorder, substance dependency), chronic obstructive airways disease, and alcohol abuse, died from cardiopulmonary arrest and respiratory failure.…
71y · Female·Diffuse Lymphoid Malignancy
…ancy (high-grade lymphoma) discovered shortly before her death. She had extensive comorbidities including chronic heart failure, renal impairment, diabetes, and COPD. While receiving medical care both in custody and at …
64y · Male·Multiple organ failure due to paracetamol toxicity
A 64-year-old man died from multiple organ failure due to chronic paracetamol toxicity after taking regular paracetamol 500mg four times daily for over 12 years for pain m…
32y · Female·Perforation of the bowel in the context of constipation and intellectual disabil…
Jessica Louis, a 32-year-old non-verbal woman with intellectual disability and Opitz Trigonocephaly Syndrome, died from bowel perforation secondary to severe constipation and pica (compulsive ingestion of non-food items)…
84y · Male·Acute myocardial infarction precipitated by upper gastrointestinal haemorrhage f…
…current use of a naturopathic cherry juice product and rivaroxaban. Symptoms were masked and presented as anaemia. Critical learning points: anticoagulant choice should consider patient's transfusion refusal status; cli…
68y · Male·Multi-organ failure due to gram-negative sepsis on a background of recent myocar…
A 68-year-old male prisoner with multiple comorbidities (diabetes, end-stage renal failure, COPD, morbid obesity) presented with acute myocardial infarction and underwent coronary artery bypass grafting. Post-operatively…
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