84 results
36y · Male·Hanging (Mr Sharma); Homicide by smothering/suffocation or chloroform exposure (…
Nilesh Sharma, a 36-year-old Fiji Indian man, killed his wife Preetika, son Divesh (5 years old), and daughter Divya (3 years old) between 28-29 April 2012, then died by hanging. Evidence suggests he exposed them to chlo…
47y · Male·pulmonary thromboembolism and deep vein thrombosis
Paul Finck, 47, an involuntary psychiatric patient with schizophrenia, died from pulmonary thromboembolism and deep vein thrombosis while admitted to the psychiatric ward. He presented with fever, tachycardia, elevated C…
10y · Male·Hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…
A 10-year-old boy with severe obstructive sleep apnoea and morbid obesity died from hypoxic brain injury following cardiorespiratory arrest. Despite repeated medical interventions and explicit warnings that his condition…
10y · Male·hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…
AA, a 10-year-old boy with morbid obesity and severe obstructive sleep apnoea, died from hypoxic brain injury after a cardiorespiratory arrest. He had been admitted to hospital in May 2008 with these diagnoses and was pr…
42y · Male·Cardiac arrhythmia secondary to electrolyte imbalance (hyperkalaemia) and verapa…
Glen Kingsun, 42, died from cardiac arrhythmia secondary to electrolyte imbalance and verapamil toxicity. He had complex medical needs requiring multiple specialist and GP care. Critical failures occurred: (1) Medication…
37y · Male·hypoxic brain injury secondary to cardiac arrest as a result of bowel volvulus
A 37-year-old man with intellectual disability, autism, and Hirschsprung's disease living in supported residential care died from hypoxic brain injury secondary to cardiac arrest caused by bowel volvulus. He had presente…
61y · Female·Peritonitis due to anastomotic leak at gastrectomy site; pathological obesity as…
A 61-year-old woman with pathological obesity died from peritonitis secondary to anastomotic leak following laparoscopic sleeve gastrectomy. The procedure itself was appropriate for her failed previous lap band surgeries…
48y · Female·Aspiration of stomach contents and pneumonia, following cardiac arrest
Margaret Webber, aged 48, with cerebral palsy and diabetes, died from aspiration of stomach contents and pneumonia. She presented to hospital with diabetic ketoacidosis (DKA) and coffee-ground vomit, which raised concern…
65y · Female·Liver failure secondary to paracetamol toxicity
A 65-year-old retired nurse died from paracetamol toxicity and liver failure after taking excessive paracetamol tablets for pain relief following a fractured arm. She presented to hospital on Saturday with a fracture. Cr…
63y · Male·Multiple blunt force injuries and mechanical asphyxia
Albert Constable, a 63-year-old heavy vehicle driver, died when his truck suddenly swerved across the median strip and crashed into a building at approximately 11:30 PM on 23 May 2013. The coroner found no mechanical fau…
24y · Female·diabetic ketoacidosis in the setting of diabetes mellitus
Kylie Anne Lightfoot, a 24-year-old woman with type 1 diabetes, died from diabetic ketoacidosis. She presented to Dr Selvan's practice on 4 May 2007 with abdominal pain, having not checked her blood sugar or taken insuli…
24y · Female·hypoxic brain injury following unexplained cardiorespiratory arrest
A 24-year-old female with brittle Type 1 diabetes and multiple comorbidities presented to Joondalup ED with a rapidly spreading blistering rash on 3 September 2009. Dr C. appropriately identified a potentially serious de…
68y · Male·infarction of the small and large bowel due to superior mesenteric artery thromb…
A 68-year-old man with extensive systemic vascular disease presented with 10 days of nonspecific abdominal pain. Initial presentations at local hospital and GP were attributed to possible gallstones or gastritis based on…
81y · Male·Acute myocardial infarction in association with coronary artery atherosclerosis
Robert Charles Bropho, an 81-year-old Aboriginal man imprisoned since 2008 with severe medical comorbidities including insulin-dependent diabetes, hypertension, chronic renal failure, and severe ischaemic heart disease, …
34y · Male·coronary atherosclerosis (heart attack)
A 34-year-old Aboriginal male died of coronary atherosclerosis while in custody. He had type 2 diabetes diagnosed in 2007 but was non-compliant with medications and lifestyle modifications. Upon reception to prison, he w…
61y · Male·ischaemic heart disease with significant atherosclerotic narrowing of all three …
Lindsay Allan Fry, a 61-year-old prisoner with poorly controlled Type II diabetes, died of ischaemic heart disease while in custody at Yatala Labour Prison. Autopsy revealed marked coronary artery atherosclerosis, myocar…
68y · Male·Abnormal heart rhythm (arrhythmia) precipitated by coronary atherosclerosis and …
John Martin Heywood, a 68-year-old prisoner, died of natural causes (arrhythmia precipitated by coronary atherosclerosis and phaeochromocytoma) while in custody at the Princess Alexandra Hospital Secure Unit. He had been…
82y · Female·Complications from hypoglycaemic brain damage and cerebral vascular accident
Margaret Allan Johnston, 82-year-old admitted for UTI and confusion, was found comatose on 4 September 2006 with severe hypoglycaemia (glucose 0.8 mmol/L) despite being non-diabetic. Blood tests revealed high insulin and…
Female·Stacey Meas: severe closed head injury from motor vehicle collision. Courtney Me…
Two deaths resulted from a motor vehicle collision caused by a driver with poorly managed insulin-dependent diabetes. Stacey Meas, a pregnant woman, died from head injuries sustained when the driver's car struck hers at …
17y · Female·Multi System Failure following acute onset (Acute Diabetic Ketoacidosis) Diabete…
Lee Rebecca Halford, a 17-year-old girl, died of acute diabetic ketoacidosis (DKA) following undiagnosed Type 1 diabetes. She initially presented to a GP with vomiting on 27 February 2007, diagnosed with gastroenteritis.…
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