38 results
52y · Male·Acute Respiratory Distress Syndrome
Neville Towner, a 52-year-old man serving a life sentence, died from acute respiratory distress syndrome (ARDS) secondary to severe community-acquired pneumonia. He presented to hospital on 15 June 2018 with respiratory …
67y · Male·Gas gangrene with antecedent cause of Clostridium septicum septicaemia
Peter Smith, 67, presented to Cooma Hospital with severe leg muscle cramps and pain on 6 February 2018. Despite appropriate pain management and initial investigation suggesting rhabdomyolysis, he rapidly deteriorated and…
53y · Female·multiple organ failure as a result of septic shock
Pauline Kessell, aged 53, died from septic shock caused by overwhelming sepsis following endoscopic pyeloscopy with laser lithotripsy for a 5cm infected staghorn calculus on 12 August 2015. Critical clinical lessons: (1)…
27y · Female·Septicaemia secondary to Neisseria meningitides infection
Naomi Williams, a 27-year-old Wiradjuri woman, died from meningococcal septicaemia on 1 January 2016. She presented to Tumut Hospital in the early hours with generalised aches and pains while pregnant. Despite vital sign…
42y · Male·Cardiac arrest following hypoxic ischaemic encephalopathy, likely due to E.coli …
Jarrod Wright, a 42-year-old man admitted with cellulitis, developed sepsis-related acute respiratory distress syndrome (ARDS) requiring ICU care with non-invasive ventilation. Critical failures occurred in managing his …
1y · Male·Septicaemia due to Streptococcal (Beta Haemolytic Group A) infection
Troy Almond, a 17-month-old boy, presented to the Emergency Department with fever, lethargy, vomiting, and tachycardia. Vital signs showed heart rate 173 bpm (red zone) and fever 38.9°C. Dr T. diagnosed viral illness (po…
79y · Male·Complications associated with metastatic colorectal carcinoma and diabetes melli…
Kenneth Johnstone, a 79-year-old prisoner with extensive comorbidities including metastatic colorectal cancer, diabetes, stage 4 chronic kidney disease, and osteomyelitis, died from cancer complications. He was appropria…
27y · Male·multiple organ failure due to the consequences of multiple gunshot wounds to the…
Mahmoud Houri died aged 27 in custody from multiple organ failure, a consequence of gunshot wounds sustained in 2002. The inquest examined whether appropriate care was provided on 21 August 2008 when he presented with vo…
54y · Male·Unascertained
A 54-year-old man with HIV, hepatitis C, cirrhosis, and significant immunocompromise presented with acute sepsis on 23 December 2016. Despite rapid ambulance response with sepsis protocol initiation and ICU-level aggress…
26y · Female·sepsis
Michaela Perrin, 26, died from sepsis arising from a post-caesarean wound infection caused by MRSA on 22 October 2014. She presented to the Emergency Department on 20 October with severe pain, tachycardia (125 bpm), and …
49y · Male·complications of non-small cell carcinoma of the lung
Keith Howlett, 49 years old, died from complications of non-small cell carcinoma of the lung while in custody at Junee Correctional Centre after 5 weeks of incarceration. He had complex medical needs including HIV, perip…
80y · Male·Pneumonia, with multi-organ failure in the form of liver failure (due to chronic…
Idris Griffiths, a 80-year-old man, died of pneumonia with multi-organ failure whilst in custody at Long Bay Correctional Centre. He had advanced chronic hepatitis C with cirrhosis, ischaemic heart disease, and a history…
44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)
Jimmy James, a 44-year-old man, died from pneumonia with multiple left-sided rib fractures secondary to a physical assault. He presented to Westmead Hospital ED with clinical signs of septic shock (tachypnoea, hypoxia, h…
33y · Male·hypoxic respiratory failure following right pneumonectomy for treatment of sever…
Manjit Singh, a 33-year-old Indian 457 visa worker, died from hypoxic respiratory failure following a pneumonectomy for treatment of severe pulmonary tuberculosis. He had latent TB identified pre-arrival in India. Critic…
51y · Male·Sepsis with multi-organ failure; pneumonia (multi-drug resistant Staphylococcus)…
John McFerrier, a 51-year-old man in immigration detention, died from sepsis with multi-organ failure and multi-drug resistant pneumonia, complicated by morbid obesity. He was admitted to Liverpool Hospital ICU with brea…
0y · Unknown·focal ventricular myocarditis and myonecrosis resulting from migration of a Peri…
A 10-month-old boy died from myocarditis and myonecrosis caused by migration of a PICC line into his right ventricle. The line was inserted appropriately under general anaesthetic for IV antibiotics treating periorbital …
40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…
Michael Peter Magro, a 40-year-old male inmate at a correctional facility, died on 27 December 2008 from hypoxic brain injury following cardiac disease and severe pneumonia. Critical failures in prison healthcare were id…
73y · Female·Bacterial endocarditis organism arising from a staphylococcal infection that ent…
Mary Roberts, aged 73, received a 5-year custodial sentence in September 2004. She had complex medical needs: dementia from previous strokes, diabetes requiring insulin monitoring, and Warfarin use. Justice Health provid…
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