Finding into death of PDR
78y · Male·Acute pancreatitis
A 78-year-old man with a long history of mental illness and multiple chronic physical conditions died from acute pancreatitis on 12 May 2025, nine days after presenting with nausea and vomiti…
428 results for “physical assessment”
78y · Male·Acute pancreatitis
A 78-year-old man with a long history of mental illness and multiple chronic physical conditions died from acute pancreatitis on 12 May 2025, nine days after presenting with nausea and vomiti…
47y · Male·pulmonary thromboembolism and deep vein thrombosis
Paul Finck, 47, an involuntary psychiatric patient with schizophrenia, died from pulmonary thromboembolism and deep vein thrombosis while admitted to the psychiatric ward. He presented with fever, tachycardia, elevated C…
64y · Male·Sepsis and lung collapse precipitated by burns to 35% of body sustained while sm…
…lp due to aphonia, and his clothing caught fire on 28 June 2004. Key clinical lessons: (1) active safety assessment of smoking risks must occur for patients with diminished physical capability, including neurological dis…
49y · Male·Complications of heatstroke; Hyperthermia
…ded dirt bike tour in Hawaii. He consumed significant alcohol the previous day, then engaged in strenuous physical activity in warm, humid conditions (28-29°C) while wearing heavy protective equipment. He struggled early…
59y · Female·Gunshot injuries to the head
…West Footscray, Victoria. She was shot by her partner, Philip Bracken, following an escalating pattern of physical and emotional family violence throughout their relationship. CP had experienced abuse since childhood, su…
31y · Male·Gunshot injury to the chest
…ed with the deceased's ex-partner. The shooter, fearing for his life after months of harassment including physical assault and threats, obtained an illegal firearm and discharged it in self-defence during a high-speed pu…
63y · Male·coronary artery thrombosis
…treating resident doctor and attributed to a known long-standing complication of previous oesophagectomy. Physical examination was reassuring, blood work was normal, and leave was granted progressively. The coroner found…
27y · Male·Hanging
…atient in an area with accessible hanging points despite prior staff warnings about this risk; inadequate physical observation (required 15-minute checks were not performed in person after 2:00pm, relying instead on CCTV…
53y · Male·Multiple gunshot wounds to the head
…o return to the property, but returned to pack belongings. When Bardho arrived home earlier than usual, a physical altercation ensued during which McSweeney believed Bardho was threatening him with a knife. The coronial …
51y · Female·Ischaemic heart disease
… valve damage requiring prosthetic replacement. She presented with an infected breast lesion but resisted physical examination due to severe aversion to touch during acute psychiatric crisis. Cardiology input was sought …
47y · Male·Unascertained natural causes, probably sudden cardiac arrhythmia
… weight management, and a poorly designed clip on the abalone bag. The excessive weight created insidious physical and mental stress, reducing his capacity to respond to difficulties. Evidence showed he used almost all h…
Male·aspiration pneumonia
Mervyn Roy Menzies, a 60+ year old man with intellectual and physical disabilities, died of aspiration pneumonia at Royal Hobart Hospital on 12 July 2020. He presented on 6 Ju…
13y · Female·Hanging
Melissa Standen, a 13-year-old with profound physical and cognitive disabilities (mosaicism), died from hanging at Westmead Children's Hospital after falling f…
67y · Male·coronary artery atheroma against a background of diabetes mellitus
…r than drowning. For clinicians: this case highlights the importance of pre-activity cardiovascular risk assessment in patients with multiple risk factors (age, diabetes, smoking) before strenuous activities. Patients wi…
50y · Female·acute heart failure in association with acute on chronic obstructive airways dis…
Donna Lillian Barnes, a 50-year-old woman with chronic schizophrenia and multiple physical comorbidities including morbid obesity, asthma, and poor mobility, died of acute heart failure associated…
39y · Male·neck injuries from being crushed between a hydraulic ram and hydraulically opera…
…chinery commissioning or subsequent audits despite adequate hazard identification procedures existing; no physical guarding was provided for the hidden danger point; training was fragmented between operators and maintena…
84y · Male·Bronchopneumonia in the setting of pulmonary emphysema and hypertensive heart di…
…and bipolar disorder, with poor medication compliance from 2018. He was non-compliant with care, refusing physical examination and vital sign checks in the hours before death. On the day of death, he complained of abdomi…
53y · Male·Cardiomegaly in a man with obesity and chronic liver disease
…h serious mental illness have significantly elevated cardiovascular mortality risk and require integrated physical-mental health assessment, though in this instance his acute presentation did not allow for active managem…
37y · Male·Stab wound to the left kidney
… Intervention Orders. Clinical lessons include: GPs should provide family violence referrals even without physical violence when patients report psychological distress and anxiety; Victoria Police risk assessments for FV…
45y · Male·multiple injuries sustained from a 25-metre fall down an unprotected stope when …
…tion of the stope for surveying; the deceased's misinterpretation of these instructions; inadequate risk assessment procedures (the deceased assessed a high-risk task as 'low' risk); removal of bollard warnings without c…
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