742 results
43y · Male·Coronary Atherosclerosis
Andrew Emerton, a 43-year-old prisoner with a history of substance abuse and psychiatric treatment, collapsed after vigorous exercise in custody. He called for help reporting shortness of breath and was found unconscious…
67y · Male·Acute myocardial infarction
Robert Quartermain, a 67-year-old prisoner with chronic obstructive pulmonary disease and previous myocardial infarction, suffered acute myocardial infarction while in custody. He experienced acute breathing difficulties…
57y · Male·Coronary atherosclerosis
David Samuel Morris, aged 57, died from coronary atherosclerosis while in custody at Woodford Correctional Centre on 19 November 2011. He had a significant cardiac history including dilated cardiomyopathy, atrial fibrill…
84y · Male·respiratory failure due to hospital-acquired pneumonia
Ronald Geoffrey Weeks, aged 84, died of respiratory failure due to hospital-acquired pneumonia following a hip fracture sustained in a fall at James Nash House psychiatric facility. He was serving an 8-year sentence for …
69y · Male·Advanced motor neurone disease leading to terminal respiratory failure
A 69-year-old man died in custody from advanced motor neurone disease with terminal respiratory failure. He experienced progressive arm and leg weakness from March 2009, initially attributed to angina. Neurological refer…
62y · Male·chronic congestive cardiac failure due to severe aortic valve stenosis and incom…
William Edward Hunt, aged 62, a life-sentenced prisoner, died from chronic congestive cardiac failure due to severe aortic valve stenosis and cardiomyopathy. His severe aortic stenosis was identified in 2003, but surgica…
39y · Male·Acute myocardial infarction arising from coronary artery atherosclerosis
Andrew Timothy Davies, a 39-year-old prisoner, presented with chest pain in August 2007. A 12-lead ECG was performed by Nurse Skrabl, a Division 2 registered nurse, showing abnormalities consistent with inferior myocardi…
30y · Male·compression of the neck consistent with hanging
Christopher Aaron Smith, a 30-year-old Koorie Aboriginal man remanded in custody on serious criminal charges, died by hanging in his prison cell. A critical missed opportunity occurred in November 2009 when Mr Smith atte…
56y · Male·respiratory failure due to adenocarcinoma of the lung and chronic obstructive lu…
Neville Ronald Baker, aged 56, died from respiratory failure due to adenocarcinoma of the lung and chronic obstructive lung disease. He was a life prisoner serving a sentence for murder. He had been a heavy smoker throug…
38y · Male·metastatic lung carcinoma
Thomas Brigham, a 38-year-old prison inmate, died from metastatic lung carcinoma after a delayed diagnosis. Over three months, he presented repeatedly with back pain, weight loss, poor appetite, and a persistent cough. D…
38y · Male·Acute drug toxicity due to clozapine-induced cardiac arrhythmia
A 38-year-old remand prisoner with schizophrenia on clozapine died suddenly in prison from acute drug toxicity (clozapine-induced cardiac arrhythmia). He had been transferred from psychiatric hospital to prison on 20 Jul…
34y · Male·Acute intracranial haemorrhage, malignant hypertension, renal artery stenosis
A 34-year-old man with malignant hypertension, prosthetic mitral valve, and renal artery stenosis died from acute intracranial haemorrhage while in prison custody. He presented with headache and hypertension on 13 June, …
45y · Male·exsanguination due to incised wound to neck
Lawrence McCarty, a 45-year-old man in custody on remand, died by suicide in prison on 30 April 2011 by slashing his neck with a dismantled razor blade. Clinical lessons include: (1) reception staff failed to adequately …
46y · Male·metastatic malignant melanoma
A 46-year-old man with metastatic malignant melanoma died in custody at a hospice. He was extradited from New South Wales to South Australia in April 2009 while undergoing cancer treatment. There was an 8-week delay befo…
58y · Male·metastatic multiple myeloma
Harry Richard Nylander, aged 58, died in prison custody from metastatic multiple myeloma on 25 January 2008. An inquest was mandatory due to his custodial status. Expert medical review by a senior medical oncologist conc…
58y · Male·metastatic adenocarcinomatosis with unknown primary source
A 58-year-old prisoner died of metastatic adenocarcinoma with unknown primary. In September 2006, significantly abnormal liver enzymes (GGT 2093) and hyperglycemia were detected. A December 2006 ultrasound identified an …
42y · Male·disseminated metastatic renal cell carcinoma
A 42-year-old prisoner died from disseminated metastatic renal cell carcinoma. Renal cancer was identified by ultrasound in September 2006 and confirmed by CT scan. Surgery was performed with curative intent in December …
29y · Male·Acute subdural haematoma
A 29-year-old man died from acute subdural haematoma following blunt head trauma. He was arrested for public drunkenness after a fight with a friend and lodged in police cells where he fell and struck his head on a concr…
86y · Male·Sepsis associated with a pericolic abscess, complicated by terminal large intest…
An 86-year-old life-sentenced prisoner died from sepsis associated with a pericolic abscess complicated by terminal gastrointestinal haemorrhage. He had extensive comorbidities including bilateral amputations, cardiac fa…
65y · Male·Pneumonia in a man with chronic pulmonary disease (COPD and emphysema), with asp…
Phillip Van Vegten, a 65-year-old sentenced prisoner with longstanding COPD, emphysema, and lung cancer, died of pneumonia complicated by aspiration of vomit (Wilkes Syndrome) at Royal Perth Hospital. The coroner found m…
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