57y · Female·Complications of muscular dystrophy
…eemed reasonable and appropriate. The death was not preventable; it resulted from the combined effects of cardiac failure, infection, and the progressive nature of her neuromuscular condition. The coroner found no mater…
74y · Male·cardiac and renal failure complicating treatment of infected ischaemic toes resu…
…ondary to diabetes mellitus. During his 17-day hospital stay, he developed acute renal failure leading to cardiac arrest and death. Critical failures included: failure to monitor creatinine and gentamicin levels between…
52y · Female·ischaemic and hypertensive heart disease
…(elevated GGT and ALP). The coroner examined whether dothiepin should have been reduced given the liver dysfunction. Expert evidence from hepatologists and clinical pharmacologists confirmed her liver function impairmen…
91y · Male·Complications of cerebrovascular and ischaemic heart disease in a man post anaph…
…dministration. The patient developed severe DRESS syndrome with anaphylaxis, acute kidney injury, liver dysfunction, and elevated inflammatory markers. He subsequently suffered a cerebrovascular event and died. Multiple…
86y · Female·Plastic bag asphyxia
An 86-year-old woman with delirium, depression, and multiple cardiac comorbidities died by asphyxiation with a plastic bag while in a transitional care facility. She had expr…
46y · Male·congestive cardiac failure due to cardiomyopathy and coronary artery atheroscler…
A 46-year-old man with significant cardiac and medical comorbidities died of congestive cardiac failure due to cardiomyopathy and coronary artery at…
0y · Female·Persistent pulmonary hypertension in the newborn (PPHN)
Summer Jamsek was born at 4pm on 4 April 2010 with persistent pulmonary hypertension of the newborn (PPHN) and died 5 April 2010 at Royal Children's Hospital. The coroner found Baby Summer died from PPHN but was not sati…
37y · Male·cardiac arrhythmia
A 37-year-old man died in custody from cardiac arrhythmia, with morbid obesity and concurrent psychotropic medications carrying QT-prolongation risk ide…
59y · Male·multiorgan failure complicating paracetamol toxicity
David James Dorling, a 59-year-old man with multiple sclerosis, ischaemic heart disease, and diabetes, ingested 90-100 paracetamol tablets on 1 February 2024 with suicidal intent. He attended court the next day and was r…
13y · Male·borderline myocarditis, most likely due to influenza A virus infection
A 13-year-old previously healthy boy with borderline myocarditis presented to an adult ED with flu-like symptoms, lethargy, dizziness, syncope and inability to walk unaided. Despite these concerning features, he was disc…
48y · Male·myocardial infarction due to coronary atherosclerosis (medically treated)
… Centre on 24 November 2012, shortly after discharge from Princess Alexandra Hospital following emergency cardiac stenting. The coroner concluded the PAH provided appropriate cardiac care and the stent angiography appro…
31y · Female·organ failure due to anorexia nervosa
Chloe Tupper died of organ failure due to severe anorexia nervosa at age 31. She had suffered from this illness for 17 years since age 14, receiving multiple episodes of hospital-based refeeding that never achieved lasti…
54y · Male·acute myocardial infarction
Gordon Arthur David Mitchell, 54 years old, died of acute myocardial infarction five days after successful stenting for an initial MI. He was discharged on 10 July 2019 despite presenting with chest pain, dyspnea, and co…
83y · Female·Pulmonary thromboembolism due to aortic stenosis (recent transcatheter aortic va…
An 83-year-old woman with severe aortic stenosis, atrial fibrillation, and heart failure died from pulmonary embolism one day after discharge following transcatheter aortic valve replacement (TAVI). Clinical lessons cent…
24y · Female·hypoxic brain injury following unexplained cardiorespiratory arrest
…meant initial blood results were 6 hours old on arrival. Earlier clinical assessment, appropriate triage, cardiac monitoring, and better information communication could have enabled timely recognition of deterioration.
79y · Male·Iatrogenic right ventricular injury complicating drainage of pericardial collect…
A 79-year-old man died from iatrogenic right ventricular injury sustained during attempted drainage of a post-operative pericardial effusion following coronary artery bypass grafting. During a minimally invasive sub-xiph…
81y · Female·Severe cardiogenic shock complicating cardiac surgery
An 81-year-old woman died of severe cardiogenic shock following elective aortic valve replacement complicated by intraoperative haemodynamic instability and inadequate postoperative ICU management. The surgery involved e…
31y · Male·Acute colonic pseudo-obstruction; death certificate amended to 'unascertained' -…
Cameron Yeates, a 31-year-old man with intellectual disability (IQ 64) and longstanding gastrointestinal issues, died from acute colonic pseudo-obstruction with underlying malnourishment. Key clinical lessons: (1) severe…
38y · Male·Aspiration pneumonia
…n facilities. He received no substantive physical assessment for nearly two years despite prescription of cardiac and epilepsy medications. While the cause of aspiration remained unclear (possibly seizure or arrhythmia …
60y · Male·Global cerebral ischaemia post cardiac arrest in the setting of neck compression
Joseph Pezzimenti, a 60-year-old involuntary psychiatric patient, died from cerebral ischaemia following hanging by a tracksuit cord in a Low Dependency Unit bathroom. Key clinical lessons include: communication difficul…
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