69y · Male·Hypoxic ischaemic brain injury secondary to right facial artery pseudoaneurysm r…
…a presenting with throat pain and trismus 12 days after completing chemoradiotherapy. On presentation to emergency department with bleeding, airway risk was under-recognised despite clinical assessment noting significan…
15y · Male·global hypoxic cerebral injury following medical intervention for high velocity …
… 15, sustained a penetrating head injury from a homemade air gun while with friends. Despite appropriate emergency response and comprehensive multidisciplinary medical management at Royal Children's Hospital including n…
76y · Female·pulmonary embolism due to carcinomatosis
A 76-year-old woman presented to hospital with shortness of breath and was initially diagnosed with community-acquired pneumonia and later pulmonary oedema. Both diagnoses were incorrect. She had widespread cancer (carci…
72y · Male·Haemopericardium due to anti-coagulation treatment for pulmonary thromboemboliti…
Jeffrey Brown, a 72-year-old with recent cardiac surgery (CABG), died from haemopericardium due to anticoagulation treatment for pulmonary thromboembolism. Post-mortem examination revealed fibrinous pericarditis (a known…
33y · Male·Decompensated congestive cardiac failure complicating acute myocardial infarctio…
A 33-year-old man with morbid obesity and steroid dependency presented with chest pain and light-headedness. Initial GP assessment missed acute coronary syndrome despite ECG changes on second visit. ED correctly diagnose…
44y · Female·Ischemic heart disease due to complete blockage of left anterior descending coro…
A 44-year-old woman presented with acute chest pain and troponin elevation. Coronary angiography revealed only a 30% non-obstructive lesion in the left anterior descending artery. She was discharged on aspirin alone with…
72y · Male·ischaemic heart disease secondary to coronary artery disease
A 72-year-old man with hypercholesterolaemia and obesity presented to the ED with chest pain and atrial fibrillation. Initial ECG showed no acute changes. Clinicians pursued a pulmonary embolus diagnosis based on pleurit…
44y · Male·cardiogenic shock, on a background of severe tricuspid valve regurgitation, seve…
Jeffrey Blundell, a 44-year-old man with severe intravenous drug use history, died from cardiogenic shock secondary to severe tricuspid valve regurgitation caused by infective endocarditis from non-sterile injection prac…
57y · Male·Sepsis from ischemic bowel due to superior mesenteric artery thrombus
…ith stent thrombosis in March 2020. Despite initial improvement on heparin, he deteriorated and required emergency surgery with extensive bowel resection. Multiple laparotomies followed with progressive ischemia. He die…
62y · Male·cerebral haemorrhage (intracerebral bleed, large lobar within left cerebral hemi…
A 62-year-old man presented to ED with dyspnoea, diaphoresis, and hypertension caused by an evolving cerebral haemorrhage. He was initially misdiagnosed with NSTEMI based on elevated troponin and atrial fibrillation, lea…
68y · Male·Dilated cardiomyopathy with previous aortic valve replacement and aortic graft
A 68-year-old man with aortic valve replacement died from undiagnosed dilated cardiomyopathy, with retroperitoneal haemorrhage as a contributing factor. He developed a large perinephric haematoma (1900mL) secondary to ov…
58y · Male·Hypertensive and valvular heart disease
…ar cardiology review, comprehensive monitoring, and timely acute management. However, a Code Red medical emergency was not called initially despite prison procedures requiring it for life-threatening incidents—though th…
70y · Male·bronchopneumonia in a man with intra-abdominal carcinoma and multiple co-morbidi…
Ronald Joseph Buckland, aged 70, died in custody at Fiona Stanley Hospital from bronchopneumonia with intra-abdominal carcinoma and multiple comorbidities. A life-sentenced prisoner, he had extensive medical conditions i…
73y · Male·Combined effects of cerebrovascular accident and subsequent iatrogenic related i…
…th worsening symptoms and was found to have a left internal carotid artery occlusion with large infarct. Emergency endovascular clot retrieval was performed but the artery was perforated, causing iatrogenic intracranial…
68y · Male·Complications following myocardial infarction and its treatment in a man with mu…
Salvatore Otranto, a 68-year-old prisoner with multiple severe comorbidities including ischaemic heart disease, diabetes, COPD, and chronic kidney disease, died from complications of myocardial infarction and its treatme…
81y · Male·Acute myocardial infarction in association with coronary artery atherosclerosis
Robert Charles Bropho, an 81-year-old Aboriginal man imprisoned since 2008 with severe medical comorbidities including insulin-dependent diabetes, hypertension, chronic renal failure, and severe ischaemic heart disease, …
79y · Female·aspiration pneumonia caused by aspiration of emesis secondary to small bowel obs…
Mrs Little, 79, died from aspiration pneumonia caused by small bowel obstruction post-hysterectomy surgery. The obstruction resulted from both pre-existing adhesions and a post-operative haematoma at the surgical site. C…
54y · Male·Global cerebral hypoxic injury due to or as a consequence of status epilepticus
…ivate Hospital. He was admitted following a violent altercation with police and attempted suicide. After emergency sedation with benzodiazepines and antipsychotics on 29 September, he developed profound sedation and neu…
70y · Male·Acute myocardial infarction in association with coronary artery atherosclerosis
A 70-year-old sentenced prisoner with severe ischaemic heart disease and prior myocardial infarctions died from acute myocardial infarction with coronary artery atherosclerosis. He presented with severe chest pain on 5 O…
66y · Female·retroperitoneal haemorrhage due to anticoagulation following right cerebrovascul…
A 66-year-old woman died from retroperitoneal haemorrhage following anticoagulation for stroke caused by intra-arterial central venous catheter placement. The catheter was mistakenly inserted into the right carotid arter…
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