69y · Male·plastic bag asphyxia and mixed drug toxicity (oxycodone and pentobarbitone)
John Abbott, aged 69, died from plastic bag asphyxia and mixed drug toxicity (oxycodone and pentobarbitone) while under home detention bail with electronic monitoring. He had a complex medical history including chronic o…
78y · Male·Aspiration pneumonia complicating advanced multifactorial dementia
Alec Bester, a 78-year-old man with advanced dementia (primarily alcohol-related), chronic alcoholism, emphysema, and ischaemic heart disease, died of aspiration pneumonia at the Roy Fagan Centre. He vomited after his ev…
93y · Male·general inanition on a background of cognitive impairment, congestive cardiac fa…
A 93-year-old man with dementia, heart failure, and chronic renal disease died of general inanition following a hip fracture sustained in a fall at an aged care facility. He was under a guardianship order with special po…
58y · Male·Gastrointestinal haemorrhage due to erosive gastritis
Bert Sharpe, aged 58, died from gastrointestinal haemorrhage due to erosive gastritis at Sir Charles Gairdner Hospital on 19 April 2004. He had been an involuntary psychiatric patient at Graylands Hospital since 1992, fo…
1y · Female·Oxycodone toxicity
…one toxicity after ingesting an 80mg Oxycontin tablet on 24 February 2010. Her father took Oxycontin for arthritis, stored in a bedroom drawer. A Piroxicam tablet fell on the kitchen floor; while her mother searched for…
62y · Male·Multi-organ failure following surgical repair of ruptured abdominal aortic aneur…
Robert Paul Rodda, a 62-year-old long-term prisoner with extensive medical comorbidities including ischaemic heart disease, COPD, and a known abdominal aortic aneurysm (AAA), presented with chest pain in September 2015. …
57y · Male·Intracerebral haemorrhage due to ruptured mycotic aneurysm due to infective endo…
Cary James Saunders, aged 57, a prisoner with pre-existing mitral valve prolapse and aortic regurgitation, died from intracerebral haemorrhage secondary to infective endocarditis caused by Streptococcus mitis. He present…
93y · Female·Catastrophic subdural haemorrhage resulting from head strike sustained in a witn…
Dayle Patricia Weldon, a 93-year-old woman with dementia, fell in the secure suite of an aged care facility and sustained a catastrophic subdural haemorrhage from which she died three days later. The coroner found that M…
68y · Female·mixed prescription drug toxicity (oxycodone, metoprolol, diazepam)
Ms Heraghty, a 68-year-old woman with multiple comorbidities including obesity (BMI 47.3), atrial fibrillation, COPD, and severe chronic pain, died from mixed prescription drug toxicity (oxycodone, metoprolol, diazepam) …
61y · Male·Pneumonia
Kenneth Morrison, a 61-year-old man with Down's syndrome, dementia and multiple comorbidities, died from pneumonia following hospitalisation at Casey Hospital in March 2008. Community Residential Unit (CRU) carers raised…
48y · Male·gunshot wounds to the right thigh and abdomen with fatal hemorrhage
A 48-year-old man with severe chronic pain, alcohol dependence, and mental health issues called police stating he was armed with knives and wanted to be shot. Despite being extensively supported by health services that d…
60y · Female·undetermined
Margaret Elizabeth Hills, a 60-year-old woman with chronic pain and depression from a work-related spinal injury, disappeared on 2 February 2010 from her home in Katoomba, NSW. Her skeletal remains were discovered nearly…
84y · Male·Respiratory failure complicating hospital acquired pneumonia following surgical …
An 84-year-old man died from respiratory failure due to hospital-acquired pneumonia following surgery for recurrent mandibular squamous cell carcinoma. Key clinical lessons: (1) Advanced Care Plans (ACPs) must be activel…
90y · Male·Pneumonia in a man with traumatic brain injury
Francis Robert Ward, age 90, died of pneumonia following traumatic brain injury sustained from multiple falls while imprisoned. He had numerous comorbidities including hypertension, renal impairment, and age-related frai…
51y · Female·Mixed drug toxicity
A 51-year-old woman with longstanding treatment-resistant depression, chronic pain, and suicidal ideation died from mixed drug toxicity. She intentionally overdosed on multiple medications including benzodiazepines, anti…
69y · Female·left pontine haemorrhage with re-bleeding associated with hypertensive vascular …
A 69-year-old woman died from left pontine haemorrhage with re-bleeding. On 2 February 2010, her GP referred her for a CT head scan after she reported two weeks of slurred speech. The scan on 11 February revealed a ponti…
52y · Female·Mixed drug toxicity
Deborah Marie Holtkamp, 52, died from mixed drug toxicity in July 2018 in circumstances consistent with suicide. She had a long history of depression, childhood abuse trauma, chronic pain conditions, and recent relations…
90y · Female·Multiple rib and pelvic fractures due to a fall from a wheelchair on sloping lan…
Cynthia Stevens, aged 90, died from multiple fractures sustained when her wheelchair rolled uncontrolled down a steep slope in a medical car park. The primary clinical lessons include: (1) inadequate application of wheel…
88y · Female·Complications of a stage 3 sacral pressure ulcer in a woman with dementia
Margaret Alice Cook, an 88-year-old woman with end-stage dementia, died from complications of a stage 3 sacral pressure ulcer at a palliative care unit. She had resided at Crofton House Supported Residential Services (SR…
68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…
Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mi…
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