49y · Male·Unascertained - cardiac arrhythmia with terminal aspiration in an overweight man…
…om available handover documents that Acuphase had been given. This omission meant standard post-Acuphase monitoring protocols were not implemented. While the ECG showed mild QT prolongation (490msec), experts agreed this…
51y · Male·ischaemic heart disease with myocarditis
Sajidu Rahman, a 51-year-old Rohingya man, died suddenly from ischaemic heart disease with myocarditis at a Christmas Island detention centre shortly after arrival by boat. He had a pre-existing history of diabetes, hype…
0y · Female·Pulmonary hypoplasia in the setting of ascending maternal genital tract infectio…
Hannah McNeil, a term neonate, died from pulmonary hypoplasia secondary to ascending maternal genital tract infection. She was born via emergency caesarean section after induction of labour for brow presentation. Despite…
46y · Male·Aspiration pneumonia in an obese man with a history of diabetes mellitus, obstru…
…l. Clinicians should monitor clozapine levels closely when patients change smoking habits, adhere to CRP monitoring guidelines, and ensure adequate supervision of device maintenance in vulnerable populations.
70y · Male·Coronary atherosclerosis
…nt long-term management plan existed across multiple correctional facilities; (4) Regular blood pressure monitoring and follow-up were inadequate. While expert cardiologists opined the secondary preventive care was 'impe…
43y · Female·Severe diffuse hypoxic brain injury caused by administration of supratherapeutic…
A 43-year-old woman died from severe diffuse hypoxic brain injury caused by excessive sodium bicarbonate administration during treatment of amitriptyline overdose. The treating ED consultant prescribed sodium bicarbonate…
55y · Male·Cardiac tamponade due to ruptured aortic dissection (Type A) against a backgroun…
…esult, inadequate handover between nursing staff about the chest pain history, and insufficient baseline monitoring despite atypical presentations.
17y · Female·Acute Methylenedioxymethylamphetamine (MDMA) toxicity
Gemma Thoms, a 17-year-old girl, died from acute MDMA toxicity after consuming three ecstasy tablets at the Big Day Out music festival on 1 February 2009. She collapsed and died on 2 February 2009. Key clinical lessons: …
0y · Female·bronchopneumonia caused by hypoxic brain damage caused or contributed to by meni…
A 9-month-old Aboriginal girl died from bronchopneumonia caused by hypoxic brain damage following cardiorespiratory arrest due to meningitis and seizures. During resuscitation at a rural GP clinic, a CO₂ cylinder was ina…
38y · Male·Combined effects of methylamphetamine toxicity, violent struggle, and positional…
Kevin Norris, 38, died in police custody after methamphetamine intoxication, violent police restraint at McDonald's, and positional asphyxia at Bowral Police Station. He had schizophrenia and was on a Community Treatment…
[18, 21, 23, 19, 22, 19]y · ["male", "female", "male", "male", "male", "female"]·MDMA toxicity (one case mixed MDMA and cocaine toxicity)
This inquest examined six deaths from MDMA toxicity after electronic dance music festivals in NSW between December 2017 and January 2019: Hoang Nathan Tran (18), Diana Nguyen (21), Joseph Pham (23), Callum Brosnan (19), …
54y · Female·unascertained
Carole Livesey, a 54-year-old woman with severe anorexia nervosa and major depression, absconded from Rockingham Hospital psychiatric unit on 3 October 2017 during an escorted walk in hospital grounds. She had been an in…
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