423 results for “diabetes mellitus”
57y · Male·Consequences of multiple injuries (from fall from elevated walkway)
Mladen Jovanoski, a 57-year-old remand prisoner, died from head injuries sustained after falling from a prison walkway on 11 April 2018. He had suspected metastatic thyroid cancer requiring urgent biopsy at a tertiary ho…
40y · Male·Cardiomyopathy with early pneumonia in a man with reported sleep apnoea and high…
Christopher John Debnam, 40, died from cardiomyopathy with early pneumonia and obstructive sleep apnoea. He was readmitted to Graylands Hospital's mental health ward on 20 November 2014 with acute psychiatric decompensat…
Unknown·COVID-19 infection with various comorbidities as contributing factors
This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…
38y · Male·acute cardiac arrhythmia in a man with cardiomegaly, focal coronary atherosclero…
Russell Brockliss, a 38-year-old Aboriginal man with severe treatment-resistant schizoaffective disorder and significant cardiovascular risk factors (obesity, smoking, focal coronary atherosclerosis), died from acute car…
86y · Male·multi-organ failure due to sepsis on a background of sacral pressure ulcer
An 86-year-old man died from multi-organ failure due to sepsis from a stage 4 sacral pressure ulcer after 61 days in a regional hospital. Critical failures included delayed pressure injury risk assessment (7 days overdue…
84y · Male·Acute myocardial infarction precipitated by upper gastrointestinal haemorrhage f…
An 84-year-old man with multiple comorbidities was prescribed rivaroxaban for deep vein thrombosis despite being a practicing Jehovah's Witness who refused blood transfusions. Rivaroxaban cannot be monitored or reversed,…
75y · Male·Multiorgan dysfunction syndrome complicating anastomotic leak following hemicole…
A 75-year-old man died from multiorgan dysfunction following an anastomotic leak after hemicolectomy for caecal adenocarcinoma. Initial post-operative recovery appeared normal, but he deteriorated from day 3 onwards. The…
38y · Female·Pulmonary Thromboembolism
Kellie Anne Keogh, 38, died from pulmonary thromboembolism on 10 November 2008 after complex pancreatic surgery. She had nephrotic syndrome with decreased anti-thrombin III levels, initially presenting with suspected DVT…
68y · Female·Coronary heart disease
A 68-year-old woman with diabetes, hypertension, hypercholesterolaemia, COPD and chronic renal failure presented with chest pain and dyspno…
82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…
Winifred Carpenter, 82, died 11 days after a right hemicolectomy for colon cancer from peritonitis due to anastomotic leak. Critical failures occurred on discharge day (10 March 2023): clinicians did not recognize her de…
75y · Female·pyelonephritis and pneumonia
Molly Jessie Smith, a 75-year-old woman with longstanding severe mental illness, died of pyelonephritis and pneumonia on 16 August 2009. She had been in state psychiatric care continuously for 53 years. During her final …
66y · Female·Hypoxic-ischaemic encephalopathy
A 66-year-old woman with COPD, obstructive sleep apnoea, and obesity underwent routine knee surgery at Royal Darwin Hospital. Post-operative care was inadequate. Despite dropping oxygen saturations to 88% when sedated an…
65y · Male·Cardiac arrhythmia, probably Torsades de Pointes, due to the combined effects of…
Linus Phillips, age 65, died at home in October 2014 from cardiac arrhythmia (Torsades de Pointes) precipitated by methadone prescribed with inadequate oversight. Mr Phillips had chronic pain from knee surgery, severe sl…
68y · Male·surgical complications following laparoscopic cholecystectomy for cholecystitis,…
Cyril Churchill, a 68-year-old man with multiple comorbidities, died from surgical complications after laparoscopic cholecystectomy for acute cholecystitis. Postoperatively, he developed profound hypotension. The treatin…
Multiple: pneumonia with cardiomyopathy (Kugena female); septic shock from pneum…
Concurrent coronial inquests into six Aboriginal deaths in Ceduna, South Australia between 2004-2009. All deceased had severe alcohol addiction and comorbidities including pneumonia, cardiomyopathy, liver disease, and se…
45y · Male·Environmental exposure and dehydration
A 45-year-old Aboriginal man with severe cognitive impairment (6.5-year-old equivalent English comprehension), traumatic brain injury, epilepsy and multiple medical conditions died from environmental exposure and dehydra…
Philip Byrne: pulmonary thromboembolism due to right calf deep vein thrombosis; …
Two patients died from pulmonary thromboembolism caused by undiagnosed deep vein thrombosis (DVT). Mr Byrne presented with right calf pain in February 2012; two GPs excluded DVT on clinical examination alone without orde…
51y · Female·Multiple injuries sustained from a fall from the top floor of a multi-storey car…
Justine Painter, aged 51, died from multiple injuries sustained jumping from a multi-storey carpark while an inpatient at Royal Perth Hospital (RPH). She had severe treatment-resistant schizoaffective disorder, command h…
53y · Male·Metastatic pancreatic carcinoma
Michael Sanderson, a 53-year-old Gamilaroi man, died from metastatic pancreatic cancer while in custody. Critical clinical lessons emerge: (1) failure to review pathology results within required 14-day timeframe delayed …
87y · Female·combined effects of ischaemic heart disease and chronic obstructive pulmonary di…
Epenesa Pahiva, 87-year-old resident with dementia at an aged care facility, suffered severe chemical burns from inappropriate bleach treatment prescribed by dermatologist Dr B.. The coroner found the treatment itself (h…
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