383 results
74y · Male·Sepsis complicating pyelonephritis and pseudo large intestinal obstruction (pall…
A 74-year-old man with intellectual disability, Parkinson's disease, and dysphagia died from sepsis complicating pyelonephritis and pseudo-obstruction after prolonged hospitalisation. He was admitted in February 2024 wit…
47y · Female·Aspiration pneumonia in the setting of type 1 diabetes mellitus, previous cerebr…
A 47-year-old NDIS participant with a history of stroke, diabetes, and complex comorbidities died from aspiration pneumonia at Austin Hospital. She had been living in specialist disability accommodation with support serv…
65y · Male·Aspiration pneumonia complicating urosepsis in setting of nephrolithiasis and ce…
Shane Michael Kelly, a 65-year-old man with cerebral palsy living in specialist disability accommodation, died from aspiration pneumonia complicating urosepsis secondary to nephrolithiasis. He was admitted to hospital on…
75y · Female·Infective complications of a left hand injury with diabetic ketoacidosis
A 75-year-old woman died from infective complications of a left hand wound sustained in a fall from a ladder in November 2023, complicated by undiagnosed diabetic ketoacidosis. Despite family encouragement to seek medica…
60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…
James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…
65y · Male·Adenocarcinoma with unknown primary
John Conway McKenzie, a 65-year-old prisoner with gall bladder cancer, died from adenocarcinoma with unknown primary on 30 May 2025 at St Vincent's Hospital Melbourne. He was admitted on 11 May 2025 with sepsis, at which…
2y · Female·Complications of severe anaemia and SARS-CoV2 (COVID-19) infection
A two-year-old girl died from complications of severe iron-deficiency anaemia and COVID-19 infection. She had significant feeding difficulties, took almost exclusively milk and yoghurt, and was profoundly anaemic with po…
3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…
Jade, a 3-year-old First Nations child, died from bilateral bronchopneumonia with neglect as a significant contributing factor. Her death was wholly preventable. The coroner identified critical failures: DCJ's Muswellbro…
66y · Female·Pneumonia (with Trisomy 21 and dementia as contributing conditions)
Voula Hristeas, a 66-year-old woman with Down syndrome, dementia, and intellectual disability, died of pneumonia on 31 March 2024 at her supported disability accommodation home. She had been admitted to hospital on 21 Fe…
74y · Male·Sepsis secondary to fistulating Crohn's disease and post-surgery complications f…
Christopher Essery, a 74-year-old man with complex fistulating Crohn's disease, died from sepsis following surgery on 24 January 2019. He was transferred to Princess Alexandra Hospital (PAH) on 31 August 2018 for special…
77y · Male·Aspiration pneumonia complicating retropharyngeal plasmacytoma, cervical myelopa…
Philip Walker, 77, died of aspiration pneumonia complicating retropharyngeal plasmacytoma, cervical myelopathy, COPD and atrial fibrillation while in prison custody. He had complex medical needs including dysphagia from …
76y · Male·out-of-hospital cardiac arrest in a man with coronary artery atherosclerosis and…
Graham John Butler, aged 76, was a sentenced prisoner at Acacia Prison who died from out-of-hospital cardiac arrest caused by coronary artery atherosclerosis in the context of long-standing type 2 diabetes, hypertension,…
71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation …
A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxon…
4y · Male·Haemophilus influenzae septicaemia with superimposed respiratory tract infection
A 4-year-old previously healthy male presented to Katherine Regional Hospital on 10 September 2023 with fever and eye pain. He was examined, found to have tachycardia (HR 156) and fever (39.2°C), and diagnosed with viral…
41y · Female·Cardiomegaly
Jessica Katgert, aged 41, died in custody at Dame Phyllis Frost Centre from cardiomegaly. She had a history of MSSA infective endocarditis treated in 2021 with echocardiographic changes including dilated left ventricle a…
58y · Male·Complications of community-acquired pneumonia, in a man with chronic lung diseas…
Adrian Phillips, a 58-year-old man with intellectual disability and chronic lung disease (emphysema, bronchopulmonary aspergillosis, asthma), died from community-acquired pneumonia caused by MRSA and Rhinovirus. He prese…
62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…
A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…
terminal palliative care in a girl with a clinical diagnosis of aspiration pneum…
A 12-year-old girl with severe cerebral palsy (quadriplegia) died from aspiration pneumonia whilst in state care following removal from her mother's care. Her mother, HC, had chronic benzodiazepine and opioid dependence,…
46y · Male·Aspiration pneumonia complicating epistaxis in the setting of prolonged nasal pr…
Hau Bui Nguyen, a 46-year-old man with severe acquired brain injury, dysphagia, and recurrent aspiration pneumonia, died from aspiration pneumonia complicating epistaxis following prolonged nasal prong oxygen therapy. Du…
86y · Female·Pulmonary thromboembolism in the setting of deep leg vein thrombosis, secondary …
Barbara Deal, 86, died from pulmonary embolism secondary to deep vein thrombosis 17 days after lumbar spinal fusion surgery. Critical failures included: no repeat VTE risk assessments despite policy requirements; inconsi…
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