89y · Male·combined effects of cerebrovascular accident, pneumonia and chronic cardiac fail…
An 89-year-old man with multiple comorbidities (ischaemic heart disease, diabetes, COPD) presented with chest infection and was admitted for heart failure. He suffered an acute stroke with subsequent delirium and combati…
7y · Female·Multiple abdominal injuries including traumatic rupture of the liver and stomach…
…ycemia at the time of the accident. Key clinical lessons include: (1) insulin-dependent diabetics with hypoglycaemia unawareness are at severe risk of sudden unconsciousness while driving; (2) medical practitioners have…
83y · Male·Drowning in a man with ischaemic heart disease
…termine the precipitating cause of capsizing but noted that a cardiac event (myocardial infarction) or hypoglycaemia (he had Type 1 diabetes and his wife noted he made unusual decisions with low insulin levels) may have…
55y · Male·Complications of right middle cerebral artery infarction
Simon Mark Everill, a 55-year-old man with intellectual disability and epilepsy, suffered a right middle cerebral artery infarction on 3 September 2014 after experiencing two falls during a day service activity. His symp…
65y · Male·Bleeding duodenal ulcer
A 65-year-old man with type 2 diabetes presented to hospital with haematemesis, hypoglycaemia, and postural hypotension caused by a bleeding duodenal ulcer. He was misdiagnosed with atypical pneum…
86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall
…icoagulation likely contributed to haemothorax progression. When he deteriorated the next morning with hypoglycaemia, hypoxia and hypotension, a tension haemothorax was identified. Intercostal catheter insertion was att…
89y · Male·Complications in association with a gastrointestinal illness in an elderly man w…
Raymond Sydney Cheek, an 89-year-old prisoner with multiple comorbidities including insulin-dependent diabetes, died from complications of gastrointestinal illness with acute renal failure. While medical care at Casuarin…
Female·Stacey Meas: severe closed head injury from motor vehicle collision. Courtney Me…
Two deaths resulted from a motor vehicle collision caused by a driver with poorly managed insulin-dependent diabetes. Stacey Meas, a pregnant woman, died from head injuries sustained when the driver's car struck hers at …
2y · Unknown·Hypoxic-ischaemic encephalopathy following sepsis related to abdominal surgical …
…mentation of specialist advice not to use the migrated tube; delayed recognition of IV access loss and hypoglycaemia; inadequate escalation to senior staff overnight despite MET calls; and ineffective communication betw…
10y · Male·Unascertainable
Two young children, Malachi (10 months) and Lochlan (2 years), died on 7-8 November 2008 in their mother's home en suite, with cause of death unascertainable. The mother claimed to have blacked out for approximately 10 h…
Female·Sepsis in the setting of a lotus birth
…declined antibiotics and antenatal steroids. The infant showed early signs of sepsis at SCN admission (hypoglycaemia, hypothermia, poor perfusion, mottled appearance) but improved initially. She deteriorated on day 2 wi…
71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation …
A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftri…
47y · Male·aspiration pneumonia, cerebral infarction, and diabetes mellitus
A 47-year-old man with Type 1 diabetes, previous strokes, acquired brain injury, and epilepsy died from aspiration pneumonia complicated by cerebral infarction. He had chronic aspiration risk due to atonic bowel and had …
64y · Female·head injury sustained in a single motor vehicle accident
Mrs Alyson Margaret Mellor, aged 64, died from a head injury sustained in a single-vehicle motor accident on 30 April 2022. She had type 1 diabetes managed with an insulin pump, and on the day of the accident her husband…
30y · Male·Disseminated mycobacterium avium complex infection complicating HIV infection
A 30-year-old man with HIV infection died from disseminated mycobacterium avium complex (MAC) infection. He had been subject to a guardianship order since July 2013 due to repeated refusal of antiretroviral therapy and o…
46y · Male·Complications of diabetic nephropathy
A 46-year-old man with a 25-year history of schizophrenia, poorly controlled type 2 diabetes, polysubstance abuse, and end-stage renal failure died from complications of diabetic nephropathy. He was admitted involuntaril…
16y · Male·Hypoxic/ischaemic encephalopathy in the context of diabetic ketoacidosis
A 16-year-old with Type 1 Diabetes died from diabetic ketoacidosis (DKA) precipitated by acute gastroenteritis acquired while on a school trip to Vietnam. Despite reporting vomiting at 8am on 26 September 2019, Lachlan w…
23y · Female·Arrhythmia of unknown aetiology
…sychiatric treatment was appropriate and medications did not contribute to death. Post-mortem excluded hypoglycaemia, pulmonary emboli and aspiration as causes. Expert toxicology review found no toxic drug levels and ap…
18y · Male·Drug toxicity (3,4-methylenedioxy-N-methylamphetamine (MDMA), methylone)
An 18-year-old male died from drug toxicity (MDMA and methylone) following ingestion at a music festival. He collapsed 4 hours after consuming three MDMA capsules over one hour, suffered cardiac arrest at the festival me…
76y · Female·pulmonary embolism due to carcinomatosis
A 76-year-old woman presented to hospital with shortness of breath and was initially diagnosed with community-acquired pneumonia and later pulmonary oedema. Both diagnoses were incorrect. She had widespread cancer (carci…
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