76y · Male·combined effects of acute myocardial infarction and urosepsis
Pasquale Esposito, age 76, died in custody at Lyell McEwin Hospital from combined acute myocardial infarction and urosepsis. He had extensive cardiac history including prior MI, CABG, COPD, and recent stent placement. On…
43y · Female·Multisystem organ failure and hypoxic/ischaemic encephalopathy following anaphyl…
…ta Hickey, a 43-year-old company executive with no cardiac history, died from anaphylaxis to CT coronary angiogram contrast after her employer commissioned an inappropriate screening program. The referral lacked clinica…
55y · Male·Bronchopneumonia in a man with a healing myocardial infarction
Leon Edward Balshaw, aged 55, died from bronchopneumonia complicating a healing myocardial infarction while in police custody. He was arrested on 25 January 2018 following a domestic dispute and taken to Bairnsdale Regio…
66y · Female·Ischaemic brainstem stroke
…sident with undifferentiated hereditary ataxia, intellectual disability, and dysphagia, presented to the Emergency Department on 26 November 2024 with acute focal neurological symptoms. CT imaging revealed bilateral occ…
51y · Female·undetermined - either citalopram toxicity or ischaemic heart disease
A 51-year-old woman died at home on 15 October 2013 while on home detention bail. She had been hospitalized in July 2013 following suspected drug overdose/withdrawal, during which she developed secondary kidney and heart…
81y · Male·valvular heart disease with cardiac amyloidosis
Murray Eric Clark, 81-year-old prisoner with extensive cardiac history including aortic stenosis, sick sinus syndrome with pacemaker, and recent TAVI procedure, collapsed and died in prison infirmary on 20 September 2019…
67y · Male·hypoxic respiratory failure in the setting of pneumonia, pulmonary embolism and …
Peter John Wallace, aged 67, died in custody at Lyell McEwin Hospital from hypoxic respiratory failure complicating pneumonia, pulmonary embolism, and advanced hepatocellular carcinoma. He had been imprisoned at Yatala L…
71y · Female·multiple pulmonary thromboemboli and deep vein thrombosis
…g made, no anticoagulation or thrombolytic therapy was initiated. Instead, staff waited for CT pulmonary angiogram, which was delayed due to absent pathology results, unfamiliar ordering systems, and lack of radiographe…
40y · Male·Aspiration pneumonia
…rtion. Ketamine was administered for sedation, he vomited and aspirated during tube placement, requiring emergency intubation. Despite seven weeks of ICU care with comprehensive multidisciplinary investigation and treat…
68y · Male·Lung cancer
Daniel McQuilken, a 68-year-old man in immigration detention, died from metastatic lung cancer. His lung cancer diagnosis was made while detained, likely related to his significant smoking history and prior asbestos and …
13y · Female·hypoxic ischaemic encephalopathy secondary to gamma hydroxybutyrate toxicity
…ut suffered irreversible brain injury and died two days later. The coroner found no clinical failures by emergency responders or hospital staff, and no inadequate child protection response or support services provision.…
48y · Male·Ischaemic Heart Disease in association with Coronary Arteriosclerosis
…e understood the need for treatment but made informed decisions to refuse medications on many occasions. Emergency response at the prison and paramedic care were appropriate. The coroner found no clinical negligence or …
Three separate cases: (1) Ronald Grundy - advanced atherosclerotic coronary vasc…
Three men died in custody in Tasmania between 2016 and 2017. Ronald Grundy (80) died of advanced atherosclerotic coronary vascular disease while hospitalised with pneumonia and gastroenteritis; his treatment was adequate…
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…
49y · Male·pneumonia, hypoxic brain injury and cardiac arrest
…year-old male with chronic cannabis dependence and depression developed post-surgical delirium following emergency anterior resection for perforated diverticulum. He became acutely agitated and paranoid, was detained un…
66y · Male·Coronary atherosclerosis with emphysema as secondary cause
Harold James Carpenter, a 66-year-old prisoner with significant comorbidities including ischaemic heart disease, emphysema, hepatitis C and possible malignancy, died from coronary atherosclerosis and emphysema. He presen…
61y · Male·Multiorgan failure, due to, or as a consequence of metastatic lung cancer (suspi…
Shane Anthony May, a 61-year-old prisoner, died of multiorgan failure secondary to metastatic lung cancer after 44 days in custody. He presented with COVID-19 symptoms on reception, then developed progressive respiratory…
52y · Female·Hypoxic brain injury due to hypotension in a woman with documented electrocardio…
Elizabeth Holley, 52 years old, was admitted involuntarily to a psychiatric ward with a history of three weeks of declining mental health and medication non-compliance. She received high-dose antipsychotic medications in…
71y · Male·disseminated fungal (Cryptococcus) infection of the lungs, brain and meninges
A 71-year-old man presented with fever, confusion, and gait disturbance in October 2017. A lung mass was identified on chest X-ray and presumed malignant, but inflammatory markers were unremarkable. Despite clinical dete…
62y · Male·Multi-organ failure following surgical repair of ruptured abdominal aortic aneur…
…rtic aneurysm (AAA), presented with chest pain in September 2015. Imaging revealed his AAA had ruptured. Emergency open repair was performed, during which prolonged aortic clamping caused acute renal failure requiring p…
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