91y · Female·congestive cardiac failure
…t of a suspected pelvic fracture. She deteriorated acutely in the ED with respiratory compromise requiring oxygen therapy. A MET call occurred. Following family discussions, a palliative approach was adopted without intu…
57y · Male·Aspiration pneumonia in a man with cerebral palsy, intellectual disability and L…
…ube. He presented with acute respiratory distress, hypoxia, and right-sided pneumonia. Despite antibiotic therapy and supportive measures, he deteriorated rapidly. The coroner found no preventable factors and confirmed …
31y · Male·haemorrhage due to incised wound to left arm with amphetamine toxicity as a poss…
…d him with a deep laceration to his left arm (cephalic vein injury). He was extremely combative, resisting oxygen therapy and IV access. Handcuffs were applied to the stretcher to enable safe transport and medical treatm…
59y · Male·Carcinomatosis due to adenocarcinoma of the pancreas
Dennis Petzler, a 59-year-old prisoner, died from carcinomatosis due to adenocarcinoma of the pancreas with extensive metastatic spread. He presented with abdominal pain and nausea in June 2018, initially managed as gast…
77y · Female·Pneumonia with contributing factors of acquired brain injury, Parkinson's diseas…
A 77-year-old woman with acquired brain injury, Parkinson's disease, epilepsy and intellectual disability died of pneumonia while an SDA resident. She presented with breakthrough seizures and aspiration pneumonitis on 16…
60y · Male·Neck injury, specifically fracture of the odontoid peg of the second cervical ve…
Gary Witcombe, a 60-year-old man, died from a fractured odontoid peg of the second cervical vertebra with associated spinal cord damage sustained during a physical altercation at a family birthday party. The injury cause…
30y · Male·ischaemic heart disease
Andrew Amos, a 30-year-old male prisoner, died of ischaemic heart disease on 24 January 2015. He had significant coronary artery disease (≥90% left anterior descending artery stenosis) with no preceding scarring suggesti…
7y · Male·cardiorespiratory failure in a child with cerebral palsy and epilepsy, with acut…
Child KT (Vinnie), age 7, died of cardiorespiratory failure from cerebral palsy and epilepsy after a prolonged hospital admission. He had complex medical needs including chronic respiratory disease, requiring PEG feeding…
66y · Female·Complications of pulmonary fibrosis and bronchiectasis in a woman with cerebral …
…e July 2016, she presented with respiratory distress and was admitted under general medicine with steroid therapy and antibiotics initiated. Despite escalation to the Medical Emergency Team on 1 August, her respiratory …
7y · Female·respiratory failure from severe scoliosis due to Murray Valley encephalitis
…tion order had been established after discussion with family in October 2015, restricting interventions to oxygen, suctioning, antibiotics and physiotherapy without intubation or mechanical ventilation. On admission with…
62y · Male·head, chest and pelvic injuries sustained in a cycle versus car motor vehicle in…
Jon Gorr, aged 62, died from head, chest and pelvic injuries sustained in a collision between his bicycle and a car driven by William Bennett on Tooram Road, Allansford, Victoria on 28 September 2021. The coroner was una…
83y · Male·respiratory failure due to chronic obstructive lung disease
An 83-year-old man with chronic obstructive pulmonary disease, suspected mesothelioma, and recurrent respiratory infections presented with type 2 respiratory failure and delirium secondary to hypoxia and lower respirator…
58y · Male·Complications of community-acquired pneumonia, in a man with chronic lung diseas…
…talised. Despite severe pneumonia with >38% expected 28-day mortality, he was discharged on 7 September on oxygen therapy and palliative care referral. He was found deceased two days later. The coroner found the cause of…
44y · Male·aspiration pneumonia
Christopher Hollens, a 44-year-old man with chronic schizophrenia, traumatic brain injury, spastic paraparesis, and epilepsy, died of aspiration pneumonia after a 15-day admission to Royal Adelaide Hospital. He was trans…
72y · Female·acute on chronic renal failure due to sepsis and chronic left leg cellulitis
…d, community support services could not commence due to holiday timing, and no pre-discharge occupational therapy review occurred. Within 5–6 days, she fell and remained on the floor for 24–48 hours before police welfar…
67y · Male·hypoxic respiratory failure in the setting of pneumonia, pulmonary embolism and …
…mprisoned at Yatala Labour Prison and received significant medical care including chemoembolisation, radiotherapy, and endoscopy for liver cancer discovered incidentally in 2021. In December 2022, he presented with ches…
5y · Male·Brainstem encephalitis (viral)
Rolden Ablis, aged 5, presented to Frankston Hospital Emergency Department with fever, vomiting, and dehydration on 10 December 2007. He was diagnosed with gastroenteritis and admitted for fluid resuscitation. Despite cl…
20y · Female·Cerebral anoxia consequent upon a severe acute asthmatic event
…th acute severe asthma unresponsive to initial treatment. After appropriate emergency management including oxygen, adrenaline and hydrocortisone, she was transferred to the High Dependency Unit where intubation became ne…
87y · Male·infective exacerbation of chronic obstructive lung disease
… and hypoxia. Two Inpatient Treatment Orders were appropriately made to enable medical treatment including oxygen therapy and monitoring. Chest imaging subsequently revealed emphysema and signs of infection. He deteriora…
83y · Male·pneumonia and severe acute respiratory distress syndrome caused by Legionella ba…
An 83-year-old man died from pneumonia and respiratory distress caused by Legionella bacterium. He presented with abdominal symptoms and was initially misdiagnosed as having aspiration pneumonia rather than community-acq…
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