32y · Female·Cardiac arrest due to hypoxia caused by dynamic hyperinflation arising from comp…
A 32-year-old woman with Sponastrime Dysplasia (a rare genetic bone disorder) died during elective bariatric surgery. She had undiagnosed subglottic stenosis (airway narrowing) and tracheobronchomalacia. Critical clinica…
79y · Female·pneumonia in the setting of acute peritonitis due to perforated stomach (operate…
…cation, underwent placement of a second intragastric balloon on 11 September 2008 for weight loss prior to hernia repair. On 30 January 2009, she presented with severe abdominal pain and vomiting. CT imaging confirmed ga…
64y · Male·Arteriosclerotic coronary artery and hypertensive heart disease
Clifford Deas, a 64-year-old man in custody at Long Bay Hospital Correctional Centre since December 2015, died on 5 March 2016 from arteriosclerotic coronary artery disease and hypertensive heart disease, with end-stage …
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…
61y · Male·Pneumonia
Kenneth Morrison, a 61-year-old man with Down's syndrome, dementia and multiple comorbidities, died from pneumonia following hospitalisation at Casey Hospital in March 2008. Community Residential Unit (CRU) carers raised…
53y · Male·Multiple injuries from being run over by a waste removal truck
Michael Joseph Bottomley, a 53-year-old man with chronic alcohol dependency, depression, diabetes, and hepatitis C, was fatally struck by a waste removal truck in a Perth laneway at 11:55 pm on 3 May 2012. Earlier that e…
55y · Female·Plastic bag suffocation
Alison Copeland, aged 55, died by plastic bag suffocation after living with severe physical disability and depression since suffering a subarachnoid haemorrhage in 1995. She had made multiple suicide attempts over 16 yea…
84y · Male·respiratory failure due to hospital-acquired pneumonia
Ronald Geoffrey Weeks, aged 84, died of respiratory failure due to hospital-acquired pneumonia following a hip fracture sustained in a fall at James Nash House psychiatric facility. He was serving an 8-year sentence for …
58y · Female·lymphangitic carcinomatosis leading to hypoxaemic respiratory failure and cardia…
June Nutter, a 58-year-old woman presenting with weight loss, anorexia, and unexplained shortness of breath, underwent gastroscopy and colonoscopy at a private hospital to investigate suspected gastric pathology. She had…
57y · Male·Hypoxic ischaemic encephalopathy secondary to prolonged downtime due to upper ai…
A 57-year-old man with intellectual disability and a documented history of choking died from hypoxic ischaemic encephalopathy following airway obstruction by food at a day activities program. Despite having a choking man…
79y · Male·Bronchopneumonia and acute bronchiolitis
Donald Broadribb, 79, died of bronchopneumonia and acute bronchiolitis after presenting to York Hospital on 12 October 2012 with vomiting, cough, and abdominal pain. He was discharged after nurses focused on treating con…
67y · Female·Sepsis as a result of gastric perforation
…ration after an intragastric balloon (IGB) procedure for weight loss. She had undergone fundoplication for hiatus hernia in 2012. Despite prior gastric surgery being an absolute contraindication to IGB placement—clearly …
56y · Male·Aspiration of gastric content secondary to combined drug toxicity
A 56-year-old de-registered doctor died from aspiration of gastric content secondary to combined drug toxicity. He had a long history of prescription drug dependency and multiple mental health issues. Two general practit…
66y · Female·acute necrotising haemorrhagic mediastinitis
Mrs Pratt, aged 66, underwent elective gastroscopy at Kapunda Hospital. During the procedure she heaved, and blood was noted at the gastro-oesophageal junction. She was discharged the same afternoon with pain, only to re…
67y · Female·perforated gastric ulcer; morphine toxicity also made a significant contribution
Mrs Lillian Shaw, a 67-year-old obese woman with a history of NSAID use, presented with vomiting and abdominal pain over 36 hours. A GP visited three times without performing adequate physical examination, failed to insp…
57y · Male·Multiple organ failure in consequence of peritonitis resulting from complication…
Robert Douglas Dalgleish died from multiple organ failure due to peritonitis resulting from complications of gastric banding surgery. He presented to the ED on 18 July 2002 with abdominal pain and vomiting. Dr B. appropr…
65y · Male·Cardiac arrhythmia, probably Torsades de Pointes, due to the combined effects of…
Linus Phillips, age 65, died at home in October 2014 from cardiac arrhythmia (Torsades de Pointes) precipitated by methadone prescribed with inadequate oversight. Mr Phillips had chronic pain from knee surgery, severe sl…
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