39y · Female·pulmonary thromboembolism due to deep vein thrombosis and sepsis due to pyelonep…
…th Campus with urosepsis and was found to have advanced ovarian cancer, bilateral pulmonary emboli, and a chronically infected left kidney. She was placed on a Mental Health Act treatment order due to schizophrenia rela…
79y · Female·pulmonary oedema and electrolyte imbalance, both secondary to renal failure
Mrs Mulvinskas, a 79-year-old with end-stage renal disease, renal carcinoma, diabetes, and cardiac failure, died from pulmonary oedema and electrolyte imbalance secondary to renal failure. On 21 October 2004, she became …
61y · Male·end stage renal failure, in the context of type 2 diabetes mellitus and chronic …
Robert Curtis, a 61-year-old Aboriginal man with end-stage renal disease, end-stage liver disease, and poorly controlled diabetes, was imprisoned for driving while disqualified on 4 February 2019. He fell in the prison s…
32y · Female·ischaemic heart disease complicated by upper gastrointestinal haemorrhage
A 32-year-old woman with schizophrenia presented to the emergency department with chest pain radiating to both arms, profuse sweating, and vomiting black material for several days. She also reported black stools. The fir…
52y · Male·clozapine toxicity
Andrew Kiltie, 52-year-old Aboriginal man, died from clozapine toxicity on 26 December 2007. He had been on clozapine 400mg daily for 5 years with significant clinical benefit for aggressive behaviour and psychosis, enab…
75y · Male·cerebral metastatic malignancy (lung cancer with brain metastases)
…Ballard, aged 75, died in prison custody from cerebral metastatic lung cancer. He had been diagnosed with chronic lymphocytic lymphoma in 2012 and managed at Mount Gambier Prison. In late 2014, Mr Ballard refused travel…
63y · Female·Escherichia coli septicaemia in a lady with multiple comorbidities
Helen Welsh, 63, died from E. coli septicaemia with multiple comorbidities. She presented with respiratory symptoms and underwent bronchoscopy. On discharge day, she deteriorated with fever, altered consciousness, and hy…
68y · Male·Complications of a witnessed airway obstruction from food bolus in a man with dy…
A 68-year-old man with dysphagia and bipolar disorder died from airway obstruction and aspiration pneumonia after choking on a sandwich brought by his wife during a supervised hospital meal. He had been admitted with wor…
71y · Male·metastatic papillary renal cell carcinoma
Robert Bell-Williams, aged 71, died from metastatic papillary renal cell carcinoma while in lawful custody at Long Bay Hospital on 1 February 2024. Imprisoned since 2012, he was diagnosed with renal cell carcinoma in 202…
43y · Male·complications of decompensated liver failure due to occult sepsis and retroperit…
Con Koumis, a 43-year-old man with beta-thalassaemia major requiring regular blood transfusions, died from decompensated liver failure complicated by occult sepsis and retroperitoneal haemorrhage. He was remanded in cust…
81y · Male·COVID-19 infection on a background of Type 2 Diabetes and end stage chronic kidn…
…an incarcerated since 2001, died from COVID-19 infection on a background of type 2 diabetes and end-stage chronic kidney disease. Despite multiple warnings about vaccination, Sievers refused COVID-19 vaccination, statin…
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…
55y · Male·probable sepsis in the setting of immunosuppression, a skin wound and chronic di…
…lycystic kidney disease, died of sepsis in January 2017. He presented with progressive symptoms including chronic diarrhoea, weight loss (16kg in 8 weeks), a gluteal abscess, nausea, vomiting, and deteriorating renal fu…
68y · Female·Complications of a fall with contributing factors of respiratory failure, respir…
Irene Charlish, a 68-year-old woman with longstanding schizoaffective disorder and multiple comorbidities, fell at her residential facility on 6 June 2017, sustaining a pneumothorax and rib fracture. She was admitted to …
56y · Male·unascertainable; complications of liver cirrhosis and/or exposure most likely
Delray Beasley, a 56-year-old Aboriginal man with chronic liver cirrhosis from longstanding alcohol abuse, was admitted to Kalgoorlie Hospital in May 2010 followin…
79y · Female·Ischaemic bowel in the setting of cardiomegaly, pneumonia and chronic renal fail…
A 79-year-old woman died from ischaemic bowel in the setting of cardiomegaly, pneumonia and chronic renal failure, four days after discharge from hospital following a hysterectomy for endometrial cancer. K…
70y · Male·bronchopneumonia in a man with intra-abdominal carcinoma and multiple co-morbidi…
…acute coronary syndrome; (2) repeated refusals of diagnostic investigations (colonoscopy/gastroscopy) for anaemia, delaying cancer diagnosis; (3) inadequate staff appreciation of risks from unmonitored oxygen use in ang…
64y · Male·complications in association with thermal injuries in a man with underlying chro…
Kim Vulich, a 64-year-old man with decompensated liver cirrhosis from chronic alcohol use, developed hepatic encephalopathy and cognitive impairment including possible Korsakoff syndr…
80y · Female·peritonitis due to sigmoid resection margin leak following extended right hemico…
…c leak, but this was not performed. The patient was high-risk due to age, malnutrition (low albumin), and anaemia. On day 6, hypotensive episodes met MET call criteria (BP 82/50) but no call was made. Poor documentation…
68y · Female·Complications of a right subdural haemorrhage (palliated), sustained in a fall
Vanna Vassallo, a 68-year-old with schizophrenia, chronic comorbidities and documented high fall risk, died from complications of a subdural haemorrhage sustained …
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