81y · Female·aspiration pneumonia, exacerbation of chronic obstructive airways disease (emphy…
Patricia Nina George, an 81-year-old woman detained under mental health legislation at Glenside Campus, died from aspiration pneumonia, COPD exacerbation and congestive heart failure. A critical ambulance transfer delay …
26y · Female·multiple injuries sustained as a result of being struck by a motor vehicle on th…
A 26-year-old woman with schizo-affective disorder, detained under the Mental Health Act, absconded from a psychiatric hospital and was fatally struck by a vehicle on a freeway. Clinical concerns include: (1) inadequate …
89y · Male·congestive cardiac failure due to ischaemic heart disease and aortic valve steno…
Ronald Thomas Robjohns, 89, died of congestive cardiac failure due to ischaemic heart disease and aortic valve stenosis while detained under the Mental Health Act at Glenside Hospital. He was admitted following severe de…
83y · Male·inanition with lobar pneumonia
An 83-year-old man with organic brain syndrome and severe malnutrition was detained under the Mental Health Act after being found in severe self-neglect. He was admitted to hospital where he received comprehensive multid…
Eva Arany: gunshot wound to the neck; Jeno Arany: traumatic brain damage complic…
An elderly man with severe depression, suicidal ideation, and ongoing psychiatric risk was hospitalised twice in 2000 and discharged on antidepressant medication. Despite staff identifying he owned seven firearms and pos…
80y · Male·bilateral pulmonary thromboembolism
An 80-year-old man with dementia was detained under the Mental Health Act at Howard House (Hillcrest Hospital) for confusion, aggression, and behavioural disturbance. He died three days after admission from bilateral pul…
77y · Male·multi-organ failure secondary to myocardial infarction
A 77-year-old man admitted to a nursing home after hip replacement surgery for a fractured neck of femur died from multi-organ failure secondary to myocardial infarction. He had multiple comorbidities including diabetes,…
88y · Female·sepsis of unknown origin
An 88-year-old woman with multi-infarct dementia and behavioural disturbance was detained under the Mental Health Act following assault of her GP. She presented with abdominal symptoms and deteriorating vital signs, tran…
63y · Male·respiratory arrest caused by bronchopneumonia secondary to swallowing problems c…
Angelo Cocca, aged 63, died of respiratory arrest caused by bronchopneumonia secondary to swallowing problems from severe dementia. He was an inpatient in a mental health facility under a detention order. The coroner fou…
33y · Male·Cerebral hypoxia caused by drowning
A 33-year-old man with severe intellectual disability and cerebral palsy drowned in a bath at a supported accommodation house. Carers left him unattended in the bath despite an Individual Plan stating 'full assistance re…
65y · Male·presumed death, actual circumstances unknown
Geoffrey Rupert Rallings, aged 65 years, was reported missing on 22 December 1995 and was presumed deceased. He had Alzheimer's disease with documented cognitive decline, memory impairment, and disinhibited behaviour. Hi…
69y · Female·Respiratory obstruction by aspirated food (Brussels sprout, chicken and carrots)…
Helena Czekajlo, aged 69, died from respiratory obstruction by aspirated food (Brussels sprout) at a nursing home. She had dementia and schizophrenia with a documented obsession about food and tendency to eat hurriedly. …
82y · Male·Lateral left ventricular myocardial infarction attributed to severe left circumf…
An 82-year-old man with severe chronic obstructive airways disease and dementia died of acute myocardial infarction while detained under mental health legislation in a secure psychiatric ward. He had been given clonazepa…
73y · Male·dehydration and hyperthermia
A 73-year-old man with mild dementia resident in aged care wandered from the facility on a hot day (31°C+) while taking three medications with anticholinergic properties: pericyazine, haloperidol, and oxybutynin. These d…
78y · Male·suppurative bronchitis complicating chronic obstructive airways disease (emphyse…
A 78-year-old man died of suppurative bronchitis complicating end-stage emphysema at a supported residential facility. Key clinical concerns include: (1) the general practitioner's reliance on unvetted aged care staff to…
83y · Female·Complications following fracture and surgical repair of the left hip in an elder…
Mrs Nola Inez Daniel, an 83-year-old with chronic lung disease, osteoporosis, and cardiac disease, was admitted to Regis Forrest Gardens for respite care on 24 December 2009. She sustained three falls on Christmas Day, w…
75y · Female·Hypostatic bronchopneumonia in the setting of dementia
A 75-year-old woman with intellectual disability, dementia, and asplenia died from hypostatic bronchopneumonia. She had been declining since April 2016 with progressive weight loss, increased agitation, falls, and swallo…
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