77y · Female·Complications of malnutrition in a woman with paranoid delusions
A 77-year-old woman with complex medical and psychiatric history died from complications of malnutrition while an inpatient with paranoid delusions and delirium. She was admitted following falls and required compulsory t…
72y · Male·Cranial fracture and intracranial haemorrhage from self-inflicted fall
…ld not have been reasonably prevented. The case highlights the challenges of managing acute psychosis with severe agitation and self-harm risk in involuntary patients, and the importance of continued close observation de…
76y · Male·right lower lobe pneumonia on a background of frontotemporal dementia, chronic o…
…d to hospital on 9 February 2022 with post-fall pain, sweating, and irregular pulse; imaging revealed early lung consolidation and acetabular fracture. He was treated with antibiotics and analgesia then discharged. A sec…
68y · Male·Ischaemic heart disease (operated); severe native coronary artery atheroma with …
Brian John Schulze, aged 68, died of ischaemic heart disease (operated) while subject to a Mental Health Act inpatient treatment order at Flinders Medical Centre. He …
73y · Male·Infectious Exacerbation of Chronic Obstructive Airways Disease with the Contribu…
Mr H, a 73-year-old man with chronic obstructive airways disease and Lewy body dementia, was admitted to hospital on 6 January 2021 following a psychiatric incident and w…
1y · Female·acute on chronic respiratory failure
Kara Compton, aged 22 months with Down's syndrome and chronic respiratory disease requiring home oxygen, died from acute on chronic respiratory failure following a dog bite attack. Injuri…
78y · Male·Multiorgan failure consequent upon pulmonary lacerations and haemorrhage sustain…
…tricuspid valve surgery. During the initial surgery, a small superficial laceration to the right lower lobe lung occurred, likely from pleural space manipulation or chest drain placement. This resulted in severe unexpect…
64y · Male·Complications of eosinophilic asthma with bronchiectasis and allergic bronchopul…
Wayne Mullin, a 64-year-old man with severe eosinophilic asthma, bronchiectasis, and allergic bronchopulmonary aspergillosis, died between 21 Septembe…
62y · Female·Complications of progressive motor neurone disease
Margaret Rose Ryan, 62, died from complications of progressive motor neurone disease at a palliative care unit. She had severe disability including non-verbal status, intellectual disability…
62y · Male·Multi-organ failure following surgical repair of ruptured abdominal aortic aneur…
…ul 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. Imaging …
79y · Male·acute bronchitis on a background of cardiomegaly with coronary artery disease
…erving life imprisonment, died from acute bronchitis on a background of cardiomegaly with coronary artery disease. He presented to St Vincent's Hospital with chest pain and shortness of breath, was found to have pneumon…
0y · Male·Trisomy 21 with complex cardiac anomalies complicated by pulmonary hypertension,…
Baby G, born with Trisomy 21 (Down Syndrome) and complex cardiac anomalies, died at Royal Darwin Hospital on 18 March 2023 aged 6 months. The coroner found that non-invasive prenatal testing (NIPT) should have been offer…
57y · Female·Haemothorax following acute thoracic aortic dissection in a woman with congenita…
…urner syndrome, coarctation of the aorta, and bicuspid aortic valve, presented to ED on 23 March 2012 with severe acute back and chest pain (8/10). A chest X-ray revealed widened mediastinum. She was admitted to CCU unde…
79y · Male·Pneumonia, due to or as a consequence of emphysema (chronic obstructive pulmonar…
…bert Charles Hilsley, aged 79, died of pneumonia secondary to emphysema with contributing ischaemic heart disease while incarcerated at Rockhampton Base Hospital. He had extensive comorbidities including COPD, ischaemic…
63y · Male·Respiratory failure due to acute exacerbation of chronic obstructive airways dis…
…ld involuntary psychiatric patient with longstanding schizophrenia and significant comorbidities including severe COPD, congestive cardiac failure and chronic renal failure, died from respiratory failure due to acute exa…
83y · Female·decompensated right heart failure (cor pulmonale) immediately following mitral v…
…mmediately following mitral valve replacement surgery. She had chronic pulmonary hypertension secondary to severe mitral regurgitation from mitral valve prolapse. The coroner investigated whether earlier diagnosis by her…
49y · Male·complications of non-small cell carcinoma of the lung
Keith Howlett, 49 years old, died from complications of non-small cell carcinoma of the lung while in custody at Junee Correctional Centre after 5 weeks of incarceration. He had complex medical needs …
33y · Male·hypoxic respiratory failure following right pneumonectomy for treatment of sever…
…d Indian 457 visa worker, died from hypoxic respiratory failure following a pneumonectomy for treatment of severe pulmonary tuberculosis. He had latent TB identified pre-arrival in India. Critical clinical lessons includ…
76y · Male·exsanguination secondary to pulmonary aortic fistula and thoracic aorta aneurysm…
Allan Phipps was a 76-year-old man with a known thoracic aortic aneurysm and severe depression admitted to Austin Hospital in October 2012 for unstable angina and depression management. His …
Multiple: pneumonia with cardiomyopathy (Kugena female); septic shock from pneum…
…oronial inquests into six Aboriginal deaths in Ceduna, South Australia between 2004-2009. All deceased had severe alcohol addiction and comorbidities including pneumonia, cardiomyopathy, liver disease, and seizures. Deat…
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