59y · Male·Disseminated carcinoma on a background of emphysema
Robert Fullerton, a 59-year-old Aboriginal man from Palm Island, died from disseminated carcinoma while remanded in custody at Townsville Correctional Centre. He presented with abdominal pain on 5 December 2018, was diag…
74y · Male·metastatic gastro-oesophageal adenocarcinoma
Ivan Milat, aged 74, died of metastatic gastro-oesophageal adenocarcinoma whilst in lawful custody at Long Bay Correctional Centre. He presented with gastrointestinal symptoms from October 2018, was initially treated for…
84y · Male·Chronic small bowel obstruction
…, and recurrent small bowel obstruction with terminal ileitis. Following earlier hospitalisations where colonoscopy was deemed inadvisable due to frailty and unsuitability for major surgery, he was managed conservativel…
35y · Female·Global cerebral ischaemic injury in the setting of post caecal resection for col…
…ple ED visits and hospital admissions. She was placed on a semi-urgent waiting list for gastroscopy and colonoscopy. Following admission with vomiting, constipation, and seizures, she underwent left hemicolectomy for co…
58y · Male·carcinomatosis from unknown primary
David Kevin Loader, a 58-year-old life prisoner, died from metastatic cancer of unknown primary in January 2020. He presented with multiple episodes of back, abdominal, shoulder and rib pain between July and November 201…
58y · Male·Haemophagocytic lymphohistiocytosis, due to or as a consequence of T-cell lympho…
Frank Burrows, a 58-year-old male prisoner, died from Haemophagocytic Lymphohistiocytosis (HLH) secondary to T-cell lymphoma. He presented with non-specific symptoms (fever, sweats, diarrhoea) and was initially discharge…
73y · Female·sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopi…
A 73-year-old woman died from sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopic revision of gastric bypass surgery. She had complex medical history with multiple post-operative complicatio…
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. …
52y · Male·complications in association with advanced malignancy (hepatocellular carcinoma)…
Jeffrey Lee Strettles, a 52-year-old prisoner, died from complications of advanced hepatocellular carcinoma, end-stage cirrhosis, and generalised sepsis. He had contracted Hepatitis C in the late 1980s and was diagnosed …
77y · Male·Complications of Metastatic Colorectal Carcinoma
Robert Fennell, a 77-year-old man serving an 18-year prison sentence, died of complications from metastatic colorectal carcinoma in Long Bay Correctional Hospital's Medical Sub-Acute Unit on 27 October 2020. He had an ex…
64y · Male·Aspiration pneumonia in a man with dysphagia and acquired brain injury
John Gale, a 64-year-old man with acquired brain injury and severe intellectual disability living in state care, died from aspiration pneumonia following a fall and pneumonia diagnosis in May 2016. He was transferred bac…
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…
65y · Male·Severe neutropenic sepsis and multi-organ failure secondary to severe mucositis …
A 65-year-old man with stage 3 rectal cancer died from severe neutropenic sepsis and multi-organ failure secondary to probable dihydropyrimidine dehydrogenase (DPD) deficiency when treated with capecitabine chemotherapy.…
75y · Female·large volume aspiration following right hemicolectomy for adenocarcinoma of the …
A 75-year-old woman with a 20-month history of iron deficiency anaemia was not investigated for its cause by her general practitioner despite clear clinical signs of deterioration. The coroner found this fell 'grossly sh…
67y · Female·bronchopneumonia and acute liver failure on a background of liver cirrhosis and …
Valerie Kelly, a 67-year-old woman with cirrhosis, hepatocellular carcinoma, and multiple comorbidities, died at Royal Perth Hospital from bronchopneumonia and acute liver failure. She was in custody at Bandyup Women's P…
70y · Male·bronchopneumonia in a man with intra-abdominal carcinoma and multiple co-morbidi…
…and delayed recognition of acute coronary syndrome; (2) repeated refusals of diagnostic investigations (colonoscopy/gastroscopy) for anaemia, delaying cancer diagnosis; (3) inadequate staff appreciation of risks from un…
58y · Male·complications of large bowel pseudo-obstruction
Paul Desmond Smith, aged 58, died from complications of large bowel pseudo-obstruction following discharge from hospital after inadequate assessment. He had presented to the ED with lower abdominal pain and severe faecal…
68y · Male·Pulmonary thromboembolus secondary to deep vein thrombosis
Ronald Wood, a 68-year-old with complex medical history including prior pulmonary emboli, was treated for rectal cancer requiring chemotherapy and major surgery. Warfarin anticoagulation was appropriately ceased due to b…
60y · Female·Cardiac tamponade due to ruptured heart due to total parenteral nutrition due to…
A 60-year-old woman died from cardiac tamponade caused by TPN fluid leaking into the pericardium through a PICC line inserted to provide nutrition following bowel surgery. The PICC line was inserted under image intensifi…
83y · Female·cardiac arrest from severe triple vessel coronary artery disease complicated by …
Margaret Isabel Horsington, aged 83, died from cardiac arrest secondary to severe coronary artery disease, complicated by large bowel obstruction from rectal carcinoma. She presented to Roma Hospital with constipation an…
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