400 results
59y · Male·hanging
A 59-year-old man with major depression and psychotic features was lawfully detained under an inpatient treatment order at Noarlunga Hospital's Morier Ward. He was appropriately managed, initially in the high-dependency …
20y · Male·gunshot wound to the chest
A 20-year-old man with borderline personality disorder, who had made over 25 suicide attempts in the two years prior, died from a gunshot wound sustained during a police encounter. He had called mental health services an…
74y · Female·Intracranial haemorrhages (non-operated) on a background of dementia
Frances Veronica Icke, aged 74, died from intracranial haemorrhages on a background of dementia. She fell at home on 31 December 2021 and was admitted to hospital with two brain bleeds. Neurosurgery determined she was no…
22y · Male·neck compression due to hanging
A 22-year-old man with treatment-resistant schizophrenia died by hanging while under guardianship with special powers of detention in supported independent living. He had attempted suicide by drinking bleach one month pr…
61y · Male·ischaemic heart disease with left ventricular hypertrophy
A 61-year-old Aboriginal man died in prison custody from ischaemic heart disease with left ventricular hypertrophy. He had significant cardiac risk factors including type 2 diabetes, hypercholesterolaemia, age, male sex,…
91y · Female·dementia complicated by subdural haemorrhage
A 91-year-old woman with advanced dementia under guardianship order died from dementia complicated by subdural haemorrhage. She sustained a fall at an aged care facility in July 2021, resulting in a 6mm subdural haematom…
62y · Male·end stage renal failure complicating oxalate crystal nephropathy with contributi…
Stewart Anthony Leane, 62, died from end-stage renal failure due to oxalate crystal nephropathy with contributing head injury. He had complex medical needs including dialysis-dependent kidney failure, schizophrenia, and …
76y · Male·right lower lobe pneumonia on a background of frontotemporal dementia, chronic o…
A 76-year-old man with frontotemporal dementia, COPD, and osteoporosis died of right lower lobe pneumonia following multiple falls causing pelvic and rib fractures at a nursing home. He was admitted to hospital on 9 Febr…
84y · Male·head and pelvic injuries with contributing ischaemic and valvular heart disease …
An 84-year-old man under guardianship with dementia, cardiac disease, and on anticoagulation suffered an unwitnessed fall at an aged care facility and sustained head and pelvic injuries. Following the fall, a registered …
85y · Male·blunt craniocerebral trauma following a fall
Anthony Donato, aged 85, died from blunt craniocerebral trauma following an unwitnessed fall at an aged care facility. He had dementia, hypertension, sleep apnoea, and previous falls. He was assessed as medium fall risk …
72y · Male·asphyxia due to upper airway obstruction due to choking on food
A 72-year-old man with acquired brain injury, seizure disorder, and dysphasia died from asphyxia due to choking on food while eating eggs and ham on toast at a disability care facility. He had no documented swallowing di…
84y · Female·Alzheimer's disease with subdural haematoma from traumatic head injury as a cont…
Mrs Betty Reid, aged 84 years with advanced Alzheimer's disease, died from Alzheimer's disease with subdural haematoma from traumatic head injury as a contributing factor. She sustained an unwitnessed fall on 1 November …
54y · Male·multi-organ failure and sepsis complicating fulminant pneumonia with empyema (op…
A 54-year-old man died from sepsis and multi-organ failure secondary to fulminant pneumonia with empyema. He presented to his GP on 1 April 2021 with concerning signs including bilateral oedema, fever, and respiratory sy…
60y · Female·sepsis due to community acquired pneumonia
Lynne Patricia Fisher, 60, presented to Mount Barker Hospital ED on 26 September 2018 with bilateral community-acquired pneumonia and was discharged after 6.5 hours despite clinical deterioration. She collapsed at home w…
30y · Female·tricuspid valve bacterial endocarditis
Jennifer Collins, a 30-year-old intravenous methylamphetamine user, died from tricuspid valve bacterial endocarditis on 6 September 2018. She presented to Noarlunga Hospital ED on 20 August 2018 with chest tightness, fev…
41y · Female·salt water drowning
Ms Ardebby Chua, a 41-year-old woman with no snorkelling experience, died from salt water drowning during a guided snorkelling tour near Blyth Island, South Australia. She aspirated water triggering laryngospasm and beca…
45y · Male·Liver failure due to metastatic hepatocellular carcinoma
A 45-year-old male prisoner died from liver failure due to metastatic hepatocellular carcinoma. He had been prescribed cyproterone (Androcur) for 20+ years as an anti-libidinal agent, with regular blood tests monitoring …
37y · Male·mixed drug toxicity with fentanyl as the principal agent
37-year-old Jason Cullen died from mixed drug toxicity with fentanyl as the principal agent. He had chronic idiopathic intracranial hypertension requiring multiple neurosurgeries and was prescribed opioids and benzodiaze…
58y · Male·acute bronchopneumonia
Giovanni Trotta, aged 58, died in custody from acute bronchopneumonia. He was a vulnerable prisoner with COPD, schizoaffective disorder, and profound deafness. Clinical lessons include: (1) hospital discharge summaries m…
61y · Male·congestive cardiac failure due to cardiomegaly with left ventricular hypertrophy
A 61-year-old man with diabetes, obesity, and high cholesterol presented to his GP with shortness of breath for 4-5 days and tachycardia (HR 120). The GP diagnosed anxiety instead of cardiac failure, failed to ask critic…
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