85y · Female·Coronary artery disease and heat exposure
An 85-year-old woman with coronary artery disease was admitted to a low-care supported residential service following bowel surgery. She was frail, hard of hearing, wore spectacles, and showed signs of confusion and distr…
51y · Male·pulmonary thromboembolus secondary to left deep vein thrombosis
Darren Templeton, a 51-year-old man with obesity (BMI 31.5), died of pulmonary thromboembolism and left deep vein thrombosis six days after undergoing left knee arthroscopy. Critical clinical lessons: (1) VTE risk assess…
87y · Male·Combined effects of sotalol toxicity on a background of severe valvular and athe…
An 87-year-old man with Alzheimer's disease died in a residential aged care facility after ingesting Sotalol, a cardiac medication not prescribed to him. The medication trolley was left unlocked and accessible despite fa…
59y · Male·complications of viral liver cirrhosis with hepatocellular carcinoma
…ng decisions in December 2019 when Mr Morgan changed his mind about treatment and resuscitation. While the cancer diagnosis ultimately proved terminal, earlier appropriate monitoring and clear patient communication might…
86y · Male·Aspiration Pneumonia secondary to Recurrent Colorectal Carcinoma
An 86-year-old man died from aspiration pneumonia following bowel preparation for elective colonoscopy. He was admitted to an outlying ward rather than the gastroenterology unit, where nursing staff documented multiple e…
69y · Male·septic shock due to infected decubitus ulcers complicated by osteomyelitis
A 69-year-old man with Parkinson's disease died from septic shock caused by infected pressure ulcers (stage 4 decubitus ulcers with osteomyelitis) that developed in aged care. Pressure sores appeared within 31 days of ad…
56y · Male·complications of viral hepatitis related advanced-chronic liver disease (medical…
… history of hepatitis C and cirrhosis. In November 2024, he was diagnosed with aggressive multifocal liver cancer and classified as Stage 3 terminally ill. A critical issue identified was Russell's missed appointment on …
60y · Male·Haemorrhage complicating a left robotic upper mediastinal lymph node clearance i…
Brett Maybus, aged 60, died from massive haemorrhage following robotic mediastinal lymph node dissection for recurrent metastatic squamous cell carcinoma. The coroner found the fatal bleed was likely caused by rupture of…
68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pul…
Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in…
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…
45y · Female·Multi-organ failure due to septicaemia and peritonitis due to faecal leakage fro…
…an failure following failure of a loop colostomy created for management of an anastomotic leak after bowel cancer surgery. The initial anastomotic leak (1.5 cm) was contained and reasonably managed conservatively. Howeve…
71y · Male·Complications of metastatic squamous cell carcinoma (terminal palliation)
Leslie Shortte, a 71-year-old life prisoner, died from metastatic squamous cell carcinoma with complications. Critical failures in his prison medical care included: failure to complete annual health assessments after 201…
84y · Male·Complications of fracture left humerus neck due to fall due to hyperactive delir…
An 84-year-old man with Alzheimer's disease and dementia-related behaviours developed a urinary tract infection causing acute delirium, atrial fibrillation, and multiple falls. After presenting to the emergency departmen…
45y · Male·metastatic malignant melanoma
Craig Lingwood, a 45-year-old prisoner, died from metastatic melanoma in May 2011. He first complained of a suspicious mole (red, itchy, bleeding) in 2005-2006, but the prison doctor (Dr C.) assessed it as benign in Augu…
26y · Male·Neck compression from hanging
A 26-year-old man died by hanging in his correctional centre cell on 26 October 2011. He had a history of mixed personality disorder, anxiety, opiate dependence and previous suicide attempt (age 13), but was not assessed…
38y · Male·Sepsis complicating bronchopneumonia and chest wall abscess in the setting of an…
A 38-year-old man with secondary adrenal insufficiency from childhood chemoradiation died from sepsis complicating a chest wall abscess and bronchopneumonia, precipitated by an adrenal crisis. He presented to his GP with…
28y · Female·aspiration of gastric contents complicating laxative abuse
…man died from aspiration of gastric contents complicating severe laxative abuse. She fabricated a terminal cancer diagnosis to conceal anorexia nervosa and factitious disorder. During a RAH admission, a CT scan revealed …
61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed
A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…
Christopher Salib: ischaemic heart disease with multiple prescription drug toxic…
This landmark inquest examined three deaths involving prescription drug toxicity: Christopher Salib (24, ischaemic heart disease with drug toxicity), Nathan Attard (34, multi-drug toxicity), and Shamsad Akhtar (35, multi…
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