383 results
48y · Male·Complications of human immunodeficiency virus infection with terminal palliative…
Travis Dion Baumgarten was a 48-year-old Aboriginal man serving a prison sentence at Acacia Prison in Western Australia who died on 5 December 2022 from complications of untreated HIV/AIDS. After HIV diagnosis in 1994, h…
44y · Female·COVID-19
Ms Anne-Maree Tammy Carr, a 44-year-old woman with intellectual disability, cerebral palsy, diabetes, and high cholesterol living in Specialist Disability Accommodation, died from COVID-19 pneumonia on 6 October 2024, fo…
40y · Male·Aspiration pneumonia
Alexander Cameron, a 40-year-old man with complex neurodevelopmental, neurological and psychiatric disorders including epilepsy, autism, and previous neuroleptic malignant syndrome (NMS), died from aspiration pneumonia f…
Unknown·COVID-19 infection with various comorbidities as contributing factors
This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…
58y · Male·multiorgan failure due to sepsis resulting from repeatedly fractured left humeru…
Wayne Anthony Lowe, aged 58, died of multiorgan failure due to sepsis following repeated humeral fractures sustained in falls. He was admitted with a right proximal humeral fracture from an intoxicated fall, discharged a…
65y · Male·Middle cerebral artery stroke in a man with multiple medical co-morbidities
Winfried Medenbach, a 65-year-old man with tuberous sclerosis, severe intellectual disability, epilepsy, and history of bowel complications, died from a middle cerebral artery stroke. He had been admitted to hospital in …
65y · Male·Multiple organ failure of unknown origin
Kevin Parkhill, a 65-year-old NDIS participant with type 2 diabetes, chronic kidney disease, chronic liver disease and congestive cardiac failure, developed a Stage IV heel wound while in supported accommodation. Despite…
50y · Male·Sepsis of unknown organism in respiratory
Mark Ruth, a 50-year-old NDIS participant with cerebral palsy, intellectual disability, chronic dysphagia, and obstructive sleep apnoea, died from sepsis of unknown respiratory organism. He had experienced declining heal…
68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pul…
Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in…
60y · Female·Complications of urinary tract disease in the setting of COVID pneumonitis on th…
A 60-year-old woman with complex comorbidities (diabetes, post-stroke paralysis, hypertension, ischaemic heart disease) residing in specialist disability accommodation tested positive for COVID-19 on 31 August 2023. She …
58y · Male·Aspiration pneumonia
Robert Djurovich, a 58-year-old man with Down syndrome, dementia, epilepsy, and gastro-oesophageal reflux disease, died from aspiration pneumonia on 1 January 2023 after admission to Maroondah Hospital on 1 November 2022…
64y · Female·End stage renal failure in the setting of sepsis
Elizabeth Shine, a 64-year-old NDIS participant living in Specialist Disability Accommodation, died from end-stage renal failure complicated by sepsis. She presented with a blocked parotid gland treated with antibiotics.…
45y · Female·COVID pneumonia complicated by severe electrolyte abnormalities
A 45-year-old woman with cerebral palsy, Smith-Lemli-Opitz syndrome, and blindness died from COVID pneumonia complicated by severe electrolyte abnormalities. She was admitted three times over 3 weeks with progressive ele…
37y · Male·Pseudomonas pneumonia
Peter Keating, a 37-year-old man with cerebral palsy and intellectual disability living in supported accommodation, died from pseudomonas pneumonia following a month-long hospitalisation. He was admitted in November 2022…
59y · Female·Urosepsis in the setting of multiple sclerosis
Jannene Wilson, a 59-year-old NDIS participant with multiple sclerosis residing in specialist disability accommodation, died from urosepsis following hospital admission for abdominal pain and nausea. The coroner found no…
69y · Male·complications post trauma related acquired brain injury
A 69-year-old man died from complications of acquired brain injury sustained in a violent assault in December 2021. He had suffered a significant intracranial haemorrhage, facial fractures, and left hemiplegia, requiring…
0y · Unknown·unascertained
A 10-day-old neonate born at 36 weeks gestation presented to hospital with signs of sepsis including hypothermia, lethargy, poor feeding, and jaundice. Critical failures in recognition and triage occurred: the infant was…
65y · Male·Aspiration pneumonia with antecedent cause of secondary progressive multiple scl…
Darryle Rodney Gilbert, a 65-year-old man with secondary progressive multiple sclerosis, died from aspiration pneumonia on 30 December 2022 at Austin Hospital. He had been admitted on 19 December 2022 with aspirated pneu…
48y · Female·Pneumonia with anaphylaxis (treated), cerebral palsy, and epilepsy as contributi…
Narelle Sanders, a 48-year-old woman with cerebral palsy and epilepsy living in disability accommodation, died of pneumonia complicated by anaphylaxis. She was admitted with shortness of breath and cough following recent…
82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis
An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was …
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