54y · Male·incised wound to the neck
…ral information and recent history were not communicated or accessed by prison staff; (5) unmanaged chronic pain from untreated shoulder injury and alcohol withdrawal contributed to distress. The coroner found the hospit…
32y · Female·massive postpartum intracerebral haemorrhage of spontaneous hypertensive origin
…idly to 189-197 systolic/88-112 diastolic between 18:00-19:00 hours accompanied by chest, epigastric, and shoulder pain. Dr F. attended at 18:00 hours, recognized dangerously high systolic pressure (189/90), but attribut…
83y · Female·meningitis with sepsis with the likely source of infection being a large and dee…
Dorothy Jean Atkins, aged 83, died on 9 July 2017 from meningitis and sepsis secondary to a large stage 4 sacral decubitus ulcer. Autopsy revealed severe malnutrition (24.5kg, BMI 13), poor hygiene with faecal soiling un…
38y · Female·Multiple injuries sustained when struck by a train
…stained a workplace injury in October 2018 involving a Work Assisted Vehicle incident affecting her back, shoulders and neck. Subsequently, she reported being bullied and isolated by colleagues, with management failing t…
48y · Female·Sepsis due to pulmonary and cutaneous infections, with urinary tract infection a…
A 48-year-old tetraplegic woman died from sepsis originating from a necrotic sacral pressure wound. Multiple system failures contributed: inadequate pressure sore prevention at the disability care provider (air mattress …
31y · Male·Lymphocytic Myocarditis in association with Acute Pericarditis (viral origin, ae…
…te pericarditis (viral origin). He presented to Carnarvon Regional Hospital on 20 December with chest and shoulder pain, weakness, and lethargy following previous pneumonia in October. Initial investigations suggested in…
26y · Male·Multiple drug toxicity and bronchopneumonia
Daniel James Hall, aged 26, died on 31 July 2010 from multiple drug toxicity and bronchopneumonia after consuming approximately 10-12 OxyContin tablets over 24 hours, vastly exceeding the prescribed dose of one tablet ev…
42y · Male·heroin and methylamphetamine toxicity
Simon Miles, a 42-year-old First Nations man with severe heroin and methylamphetamine dependence, died from accidental drug overdose while on Stage 2.5 of the Compulsory Drug Treatment Program (CDTP). Despite progressing…
46y · Female·Complications following cardiorespiratory arrest in association with an air embo…
… but failed to read nursing notes documenting signs of sepsis (green bile drainage, elevated vital signs, shoulder tip pain), instead documenting her as 'stable'. On 12 November, critical observations showing respiratory…
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