60y · Male·atherosclerotic heart disease (cardiac arrhythmia secondary to severe long-stand…
Paul Stephen Keating, a 60-year-old man with severe atherosclerotic heart disease, died from cardiac arrhythmia while incarcerated in Casuarina Prison, Western Australia. He had significant coronary artery …
63y · Male·ischaemic heart disease
… 2018 on medical management with outpatient cardiology follow-up. He died suddenly the following day from cardiac arrest secondary to ischaemic heart disease. Expert cardiology review confirmed discharge was appropriate…
35y · Male·atherosclerotic heart disease with methylamphetamine effect in a man under physi…
A 35-year-old male with severe pre-existing ischaemic heart disease and recent cardiac arrest (April 2016) presented with increasingly erratic and paranoid behaviour after methylamphetamine us…
24y · Male·Cardiac arrest in a man with Sotos syndrome and multiple comorbidities, includin…
Joshua Fredrik Van Malssen, a 24-year-old man with Sotos syndrome, complex cardiac disease, asthma, and obesity, died from cardiac arrest after being restrained in the prone position durin…
83y · Male·Congestive cardiac failure due to ischaemic and valvular heart disease, with her…
Frank Valentine, an 83-year-old man, died from congestive cardiac failure due to ischaemic and valvular heart disease, with hereditary haemorrhagic telangiectasia (HHT) an…
64y · Male·Complications of redo thoracotomy/aortic valve replacement in a man with ischaem…
A 64-year-old physician with significant cardiac history (prior CABG, pacemaker, congestive failure, and newly severe aortic stenosis) underwent redo thor…
75y · Male·acute bronchopneumonia in a man with comorbidities
… from acute bronchopneumonia with comorbidities. Mr Rice had extensive medical complexity including COPD, cardiac disease, peripheral vascular disease, and diabetes. He was appropriately placed on the terminally ill reg…
54y · Male·acute myocardial infarction due to coronary artery atherosclerotic disease
…ery disease and recent myocardial infarction (February 2023), suffered an acute myocardial infarction and cardiac arrest while in police custody at Goulburn police station on 5 March 2023. He presented with chest pain a…
42y · Male·Ischaemic heart disease due to severe triple-vessel coronary artery atherosclero…
…e continued physical work despite cardiology advice to restrict activity. His death occurred from natural cardiac causes, not from the fall, though he fell while acutely unwell. The case highlights dangers of unregulate…
68y · Female·Haemorrhage secondary to right subclavian artery lacerations sustained during ce…
…g neck exploration and despite sternotomy and vascular repair, died from hypovolemic shock and subsequent cardiac compromise. The expert review found the clinical decision-making appropriate throughout. Key learning: ul…
44y · Male·cardiac arrhythmia in a man with liver failure due to cirrhosis and focal corona…
…44-year-old prisoner with end-stage liver cirrhosis secondary to hepatitis C and alcohol abuse, died from cardiac arrhythmia at Sir Charles Gairdner Hospital. He had been receiving aggressive treatment for his advanced …
46y · Female·hypoxic ischaemic brain injury as a result of cardiac arrest following a choking…
…e, and that her choking was likely due to impulsive eating behaviour rather than ODS-related swallowing dysfunction. No clinical negligence was found. The hospital subsequently implemented improved emergency response pr…
72y · Female·Peritonitis due to perforated diverticulum in transverse colon
Maria Donatelli, a 72-year-old woman with cardiac and renal disease, presented to Peel Health Campus with abdominal pain and vomiting. She was initially ma…
39y · Male·cardiac arrest caused by alcoholic cardiomyopathy
Ryan Smiler was a 39-year-old Aboriginal man who died from cardiac arrest caused by alcoholic cardiomyopathy while in custody at Darwin Correctional Centre. He had a long h…
31y · Female·hypoxic ischaemic encephalopathy, bronchopneumonia and myocardial ischaemia comp…
…evented worse outcomes but should never be standard practice. While her prognosis was extremely poor from cardiac collapse, equipment failures fell below acceptable standards for custodial healthcare.
68y · Male·pulmonary thromboembolism in the setting of recent surgery
…operation. A MET call at 5:30am revealed non-specific symptoms consistent with several diagnoses (sepsis, cardiac event, PE). Clinical examination, investigations and differential diagnosis approach were appropriate at …
72y · Male·acute cerebral infarction complicating acute myocardial infarction
…ood survival prospects (70-80%). When Bromage presented again on 1 March with fever and loss of appetite, cardiac causes were not considered. He collapsed that evening with extensive anterior myocardial infarction and t…
58y · Male·Aspiration pneumonia in a man with a left middle cerebral artery stroke (palliat…
Brian Lench, a 58-year-old man with intellectual disability in DHS residential care, suffered a left middle cerebral artery stroke on 6 October 2011. He developed aspiration pneumonia complicated by acute respiratory dis…
24y · Male·methylamphetamine toxicity
LT, a 24-year-old male prisoner, died from methylamphetamine toxicity after ingesting multiple drug-filled balloons that ruptured in his stomach. He had received a prison visit from two individuals with prior contraband-…
62y · Male·chronic congestive cardiac failure due to severe aortic valve stenosis and incom…
William Edward Hunt, aged 62, a life-sentenced prisoner, died from chronic congestive cardiac failure due to severe aortic valve stenosis and cardiomyopathy. His severe aortic stenosis was identified…
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