75y · Male·Complications of chronic renal disease on a background of hypertension and type …
Conway Perrie, a 75-year-old man in lawful custody at Long Bay Correctional Complex, died from complications of chronic renal disease (stage 4) with hypertension and type 2 diabetes mellitus. He had been reviewed at Prin…
55y · Male·coronary atherosclerosis
Michael Reynolds, aged 55, died of coronary atherosclerosis while incarcerated. He had suffered a myocardial infarction at age 32 and subsequently refused cardiac medications despite medical advice, a decision consistent…
83y · Male·end-stage Parkinson's disease (palliated)
Raymond John Blackney, an 83-year-old man with end-stage Parkinson's disease, died in custody at Port Phillip Prison from natural causes. He had complex medical needs including dementia, intellectual disability, and mult…
53y · Male·Penetrating injuries to the right arm and chest
A 53-year-old male died from penetrating injuries to the right arm and chest on 25 November 2011. The coroner found the cause of death was stab wounds but made an Open Finding as to manner of death due to unexplained cir…
87y · Male·Ischaemic heart disease in the setting of immersion
Charles Frederick Norton, 87, was found deceased in an unsecured canal at a retirement village on 28 February 2020. He had ischaemic heart disease with severe atherosclerosis and aortic stenosis. In the week before death…
86y · Male·Sepsis associated with a pericolic abscess, complicated by terminal large intest…
An 86-year-old life-sentenced prisoner died from sepsis associated with a pericolic abscess complicated by terminal gastrointestinal haemorrhage. He had extensive comorbidities including bilateral amputations, cardiac fa…
89y · Male·Complications of choking on a food bolus in a man with multiple medical comorbid…
Maurice Benedict Costello, 89, died from aspiration of a food bolus while eating on a geriatric ward three days after a fall. He had documented oropharyngeal dysphagia requiring supervision during oral intake. Speech pat…
71y · Male·Acute myeloid leukaemia due to transformation from chronic myelomonocytic leukae…
Peter Timms, a 71-year-old prisoner with multiple comorbidities, died from acute myeloid leukaemia (AML) transformed from chronic myelomonocytic leukaemia. He made over 40 health service requests while incarcerated, incl…
81y · Male·aspiration of gastric contents complicating disseminated moderately differentiat…
Graham Joseph Butson, aged 81, died from aspiration of gastric contents complicating undiagnosed metastatic lung cancer with brain metastases. He presented with confusion, agitation and atrial fibrillation; a lung mass w…
67y · Male·ischaemic heart disease
A 67-year-old man with ischaemic heart disease and paroxysmal atrial fibrillation underwent arthrotomy for septic arthritis of the knee. He developed post-operative delirium attributed to anaesthesia, analgesics (tramado…
47y · Male·unascertained
Eric Donald Brandrick, a 47-year-old man with significant disability from a right thalamic intracerebral haemorrhage stroke in September 1988, was last confirmed alive on 31 December 1989 at Royal Perth Hospital Emergenc…
57y · Male·Mixed drug toxicity, predominantly propoxyphene (Doloxene)
A 57-year-old man died from mixed drug toxicity, predominantly propoxyphene (Doloxene), combined with benzodiazepines. His GP of 13 years prescribed Doloxene for 10 years despite documented alcohol abuse history, which w…
87y · Female·Terminal exacerbation of chronic obstructive pulmonary disease; antecedent cause…
Maureen 'Kitty' McDonald, 87, died from terminal exacerbation of COPD with an antecedent sacral pressure wound infection. She was admitted to residential aged care in October 2020 with a stage-two sacral pressure injury …
84y · Male·Acute myocardial infarction precipitated by upper gastrointestinal haemorrhage f…
An 84-year-old man with multiple comorbidities was prescribed rivaroxaban for deep vein thrombosis despite being a practicing Jehovah's Witness who refused blood transfusions. Rivaroxaban cannot be monitored or reversed,…
87y · Female·Complications following a medication administration error in a woman with multip…
An 87-year-old woman died from complications of a medication administration error at an aged care facility. During transition from paper-based to electronic medication charts in December 2020, a pharmacy data entry error…
68y · Male·Ischaemic small and large intestine complicating cardiogenic shock in the settin…
Ignac Lecek, 68, with hypertension and gout, collapsed in custody and died of ischaemic bowel complicated by cardiogenic shock in the setting of ischae…
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