34y · Male·Mixed methadone and thioridazine toxicity
A 34-year-old man died in prison from mixed methadone and thioridazine toxicity. He was on methadone maintenance (110mg daily) for opioid addiction and was prescribed thioridazine 100mg nightly for depression. Post-morte…
50y · Male·Cerebral hypoxia and bronchopneumonia post episode of choking
…Cole, age 50, was a Wyndham Lodge aged care resident with significant disabilities including post-stroke paralysis and dysphagia requiring modified diet. He died on 25 June 2009 from cerebral hypoxia and bronchopneumoni…
58y · Female·pneumonia and cardiac failure complicated by hypoxic brain injury
A 58-year-old woman with autism and severe intellectual disability died from pneumonia and cardiac failure complicated by hypoxic brain injury following cardiac arrest. She had been institutionalised at Graylands Hospita…
71y · Female·pneumonia following cervical spine fracture sustained in motor vehicle collision
Julie Anne Holmes, aged 71, died of pneumonia following a cervical spine fracture sustained in a motor vehicle accident that was not diagnosed during her hospital admission. Critical clinical lessons include: (1) paramed…
53y · Male·Complications of old brain injury in prior motor vehicle incident
Bruce Vernon Taylor, 53, died from complications of a remote brain injury sustained in childhood motor vehicle accident. He lived in shared disability accommodation and received support through NDIS. In the 12 months bef…
20y · Female·Cerebral anoxia consequent upon a severe acute asthmatic event
Sally Anne Gordon, a 20-year-old with a 14-year history of severe brittle asthma, presented to Mount Gambier Hospital on 26 November 2000 with acute severe asthma unresponsive to initial treatment. After appropriate emer…
61y · Male·Hypoxic encephalopathy arising from cardiac arrest following self-removal of a c…
Kelvin Moulds, a 61-year-old man, died of hypoxic encephalopathy following a cardiac arrest caused by self-removal of a central venous catheter (CVC) on day 14 post-bilateral lung transplant. The CVC was still in situ de…
74y · Male·Pulmonary thromboembolism secondary to deep vein thrombosis in the setting of re…
…spinal injuries. Critical failures included: (1) clinicians initially attributed neurological signs (leg paralysis, reduced sensation) to behavioural issues rather than investigating organic causes; (2) delayed CT imagi…
79y · Female·cardio-respiratory arrest consequent upon the aspiration of food
A 79-year-old woman with post-stroke dysphagia died from aspiration of food while hospitalised. A speech pathologist prescribed a minced diet after an unsuccessful soft diet trial, but the patient received a soft diet me…
72y · Female·Pneumonia following cervical spine injuries sustained in an unwitnessed mechanic…
Valma Ann Tweedie, aged 72, died from pneumonia following cervical spine injuries sustained in an unwitnessed fall at a disability support facility. She had a known history of falls, mobility problems, and probable demen…
16y · Male·Anaphylaxis due to mammalian meat allergy after tick bite, causing an acute exac…
Jeremy Webb, 16, died from anaphylaxis due to mammalian meat allergy (tick-induced) which triggered status asthmaticus. He had experienced red meat reactions since age 10 and a severe respiratory event in April 2021 that…
Multiple causes: Shane Navin - drowning; Leigh Mundy and Dennis Neagle - multipl…
A comprehensive coronial inquest into four deaths at Targa Tasmania motorsport events (2021-2022). Shane Navin drowned after his vehicle crashed into a creek; Leigh Mundy and Dennis Neagle died in a high-speed crash due …
92y · Male·periprosthetic fracture of the left hip sustained from a fall from standing posi…
A 92-year-old man with complex cardiac history was admitted to Royal Hobart Hospital with chest pain and atrial fibrillation. He remained in the Emergency Medical Unit (EMU) for five days despite clinical deterioration, …
67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…
…dation and opioids. He reported hearing a crack and subsequently developed complete bilateral lower limb paralysis (ASIA Grade A spinal cord injury at T11/T12). The incident was preventable through: proper spinal precau…
38y · Female·peritonitis with septic shock secondary to perforation of the gastrointestinal t…
A 38-year-old woman in persistent vegetative state following anoxic encephalopathy from anaphylaxis during surgery died from peritonitis caused by perforation at the gastrostomy stoma site. The perforation likely occurre…
78y · Female·Severe burns sustained while smoking
A 78-year-old woman with dementia and significant manual dexterity deficits suffered fatal burns while smoking unsupervised in an aged care facility. Despite documented cognitive impairment and physical limitations preve…
31y · Female·cerebral anoxia following attempted intubation pre-surgery in a woman with torti…
…re-operative assessment noting potential difficult intubation, he proceeded with general anaesthesia and paralysis. Subsequent attempts by multiple senior anaesthetists and the surgeon to establish an airway all failed;…
88y · Female·Acute on chronic renal failure due to dehydration on a background of Lewy body d…
An 88-year-old woman with Lewy body dementia, Parkinson's disease and congestive cardiac failure died from acute kidney injury precipitated by severe dehydration in aged care. June 2020 blood tests showed mild hypernatra…
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