3,729 results
61y · Male·Multiorgan failure, due to, or as a consequence of metastatic lung cancer (suspi…
Shane Anthony May, a 61-year-old prisoner, died of multiorgan failure secondary to metastatic lung cancer after 44 days in custody. He presented with COVID-19 symptoms on reception, then developed progressive respiratory…
52y · Female·Spinal injuries sustained in falls in a woman with multiple medical comorbiditie…
Caroline Monique Hall, a 52-year-old woman with intellectual disability, epilepsy, schizophrenia, and multiple comorbidities living in supported disability accommodation, died from spinal injuries sustained in falls. She…
53y · Male·Cervical spine distraction and hanging
A 53-year-old man with chronic treatment-resistant depression and chronic suicidality was admitted to Northern Hospital following a serious suicide attempt. He was assessed as high-risk but discharged after 19 days with …
63y · Female·Community acquired pneumonia with urinary tract infection as a significant contr…
A 63-year-old NDIS participant with multiple sclerosis residing in specialist disability accommodation died from community-acquired pneumonia with urinary tract infection as a contributing factor. She presented with ches…
73y · Male·Head injury sustained in an e-scooter accident
A 73-year-old man died from head injuries sustained in an e-scooter accident. He was riding on a non-shared footpath without a helmet, carrying unwieldy cargo in one hand which compromised vehicle control. He lost contro…
16y · Male·Complications of acute alcohol intoxication
A 16-year-old male died from complications of acute alcohol intoxication after consuming a dangerous quantity of alcohol (estimated blood alcohol content 0.34-0.4 g/100mL at midnight) at a family Christmas gathering. He …
24y · Male·Hypoxic Ischaemic Encephalopathy due to hanging
Jayke Aleckson, 24, died by hanging in a non-BDRP compliant prison health cell while on remand at Marngoneet Correctional Centre in October 2018. Key clinical lessons: (1) Multiple unmet requests for antidepressant medic…
59y · Male·Hanging
Terry Grady, a 59-year-old man with a history of alcohol dependence, depression, and chronic pain, died by suicide in custody at Parklea Correctional Facility on 8-9 August 2019. He was bail-refused for domestic violence…
79y · Male·Respiratory failure due to haemothorax and hospital-acquired pneumonia due to mu…
A 79-year-old man with extensive comorbidities died following multiple falls in residential aged care. He was identified as high falls risk on admission but experienced inadequate falls prevention after a second fall on …
62y · Male·Mediastinitis due to perforated oesophagus, with severe emphysema as a contribut…
A 62-year-old man with severe emphysema and chronic oesophageal stricture died from mediastinitis secondary to perforated oesophagus. He had undergone 46 oesophageal dilations since December 2022, with frequent mucosal t…
61y · Female·Alzheimer's Dementia and epilepsy in the setting of Down syndrome, hypothyroidis…
Luana Janiece Ross, a 61-year-old woman with Down syndrome, Alzheimer's dementia, and epilepsy, collapsed at home while being assisted with her morning routine and died shortly after. Paramedics responded promptly and in…
68y · Male·pneumonia in the setting of metastatic malignancy of unknown primary, likely bow…
Donald Charleson, a 68-year-old NDIS participant with epilepsy residing in specialist disability accommodation, was admitted to Monash Medical Centre on 19 January 2023 with pneumonia, vomiting, and chest pain. He had re…
0y · Male·Hypoxic ischaemic encephalopathy due to an out of hospital cardiac arrest second…
A 10-month-old boy drowned in a backyard fishpond after a 27-minute period of inadequate supervision. He was found unresponsive by his aunt and underwent prolonged resuscitation, suffering severe hypoxic brain injury. De…
64y · Male·Acute renal failure with significant contributing condition of stroke
Paul Munt, a 64-year-old NDIS participant with severe acquired brain injury living in supported accommodation, died of acute renal failure with stroke as a contributing condition. He was assessed by his GP on 17 July 202…
37y · Male·Pseudomonas pneumonia
Peter Keating, a 37-year-old man with cerebral palsy and intellectual disability living in supported accommodation, died from pseudomonas pneumonia following a month-long hospitalisation. He was admitted in November 2022…
64y · Female·Cholecystitis with significant contributing condition of secondary progressive m…
Marie Therese Brolan, a 64-year-old NDIS participant with secondary progressive multiple sclerosis residing in supported accommodation, died from cholecystitis following admission to hospital for recurrent gallbladder in…
61y · Female·Decompensated liver failure - Child's Pugh B cirrhosis secondary to renal failur…
Debra Louise Goold, a 61-year-old NDIS participant living in Specialist Disability Accommodation, died from decompensated liver failure (Child's Pugh B cirrhosis) and renal failure. She was admitted to Ballarat Base Hosp…
52y · Male·Right severe Middle Cerebral Artery stroke
Timothy Jeitz, a 52-year-old NDIS participant living in supported accommodation, died from a right severe middle cerebral artery stroke on 22 January 2023 at Wimmera Base Hospital. He suffered the stroke at home on 18 Ja…
66y · Female·Right middle cerebral artery and posterior cerebral artery stroke
Rose Gajica, a 66-year-old NDIS participant with advanced multiple sclerosis residing in supported accommodation, suffered two major strokes on 11 December 2022 whilst at home. Emergency services were immediately called …
5y · Female·myocarditis
A five-year-old girl died from fulminant myocarditis caused by influenza A on 5 July 2022 at Canberra Hospital. The diagnosis was delayed over 7 hours from initial presentation. Critical failures included: ED triage Cate…
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