63y · Male·raised intracranial pressure due to cerebellar metastasis arising from primary b…
Francis Seery, aged 63, died of raised intracranial pressure from cerebellar metastasis secondary to bronchogenic large cell carcinoma. Diagnosed with lung cancer in May 2001 while imprisoned, he received radiotherapy wi…
80y · Male·metastatic carcinoma
Kenneth William Glencross, an 80-year-old prisoner, died of metastatic lung cancer at Mary Potter Hospice on 8 June 2001 while on conditional leave from prison. He was diagnosed with end-stage metastatic lung cancer in M…
57y · Male·carcinoma of the right lung
Alfred Firth Thorpe, a 57-year-old man imprisoned for manslaughter, died of carcinoma of the right lung whilst in custody. He had declined radiotherapy for throat cancer in 1999, which may have prevented recurrence. Lung…
42y · Male·small cell lung cancer
A 42-year-old man imprisoned for rape died from small cell lung cancer at a hospice after a brief four-hour leave from prison. Cancer was detected within days of imprisonment when he presented with a persistent cough. He…
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…
25y · Male·positional asphyxia in a man with extensive old hypoxic brain damage, acute ches…
Corey Paddy, a 25-year-old Aboriginal man with severe hypoxic brain injury from a 1998 car accident, died at Katherine Hospital from positional asphyxia while receiving concurrent morphine therapy and suffering from acut…
80y · Male·bronchopneumonia complicated by morphine toxicity
An 80-year-old man with terminal liver disease died from bronchopneumonia complicated by morphine toxicity following a medication administration error. A Graseby infusion pump was incorrectly set at 99mm/hour instead of …
50y · Male·aspiration pneumonia (with Down syndrome as contributing condition)
Glenn Altmann, a 50-year-old man with Down syndrome, epilepsy, cognitive impairment and oropharyngeal dysphagia, died from aspiration pneumonia. He was under palliative care in the community following a January 2014 diag…
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…
77y · Male·Respiratory arrest in the setting of metastatic malignancy
An elderly man with metastatic malignancy died from respiratory arrest in hospital. The coroner found the death resulted from his underlying advanced cancer rather than medical mismanagement. No autopsy was performed, bu…
52y · Female·Unascertained (natural causes)
Jocelyn Riddiford, a 52-year-old woman with intellectual disability and autism residing in supported accommodation, died from unascertained natural causes. Over 18 months prior to death, she experienced progressive decli…
32y · Female·Aspiration pneumonia with severe cerebral palsy as underlying condition
Ella Hitchen was a 32-year-old woman with severe cerebral palsy, quadraplegia, intellectual disability, vision impairment, epilepsy and dysphagia who died from aspiration pneumonia. She had a PEG tube inserted in 2011 du…
55y · Male·Ascending cholangitis due to choledocholithiasis
A 55-year-old man with Down syndrome died from ascending cholangitis due to choledocholithiasis following recurrent biliary sepsis. He had multiple comorbidities including Alzheimer's disease, depression, and cardiac dys…
62y · Male·Multi-organ failure following surgical repair of ruptured abdominal aortic aneur…
Robert Paul Rodda, a 62-year-old long-term prisoner with extensive medical comorbidities including ischaemic heart disease, COPD, and a known abdominal aortic aneurysm (AAA), presented with chest pain in September 2015. …
62y · Male·bronchopneumonia in a man receiving terminal palliative care for metastatic carc…
Robin David Macartney, a 62-year-old prisoner serving a life sentence for murder, died from bronchopneumonia secondary to metastatic colon cancer. He was diagnosed with sigmoid colon cancer in December 2006 but refused s…
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