1,981 results
87y · Female·Natural causes in the context of multiple co-morbidities including a sacral ulce…
87-year-old woman died in aged care with a stage 4 sacral ulcer and multiple comorbidities. Key clinical lessons: (1) Systematic communication failures—family was not informed that a healed sacral wound re-emerged in Mar…
76y · Male·Hypothermia and multiorgan failure complicating compound left tibia and fibula f…
Leslie Roberts, a 76-year-old man with intellectual disability under DHHS care, died from hypothermia and multiorgan failure following a compound fracture of the left tibia and fibula sustained in a fall at home. He was …
57y · Female·multi-organ failure due to sepsis caused by streptococcus pneumoniae infection
Joanne Craig, a 57-year-old Aboriginal woman, presented to Katherine District Hospital on 24 January 2018 with fever, vomiting, and cough. She had streptococcus pneumoniae sepsis with elevated inflammatory markers from 1…
52y · Male·septicaemia caused by Streptococcus Milleri group pneumonia
Kurt Mellick Andriske, 52, died from septicaemia caused by Streptococcus Milleri pneumonia, with drug toxicity as a contributing factor. He was a complex patient with bipolar disorder, chronic pain, hepatitis B and C, an…
69y · Female·Aspiration pneumonia in a woman with intellectual disability
Elizabeth Geiger, a 69-year-old woman with intellectual disability living in a disability group home, died from aspiration pneumonia after presenting with constipation. She was seen by her GP on 24 July 2017 who examined…
34y · Male·Multiple injuries sustained when the car he was driving collided with a tree
A 34-year-old man with a history of depression and a previous suicide attempt died when he intentionally drove his car into a tree. He had been prescribed antidepressants by his GP following assessment for severe depress…
27y · Male·chest and abdominal injuries from single motorcycle crash
Jacob Wilson, aged 27, died from chest and abdominal injuries sustained in a motorcycle crash on 22 January 2018. He was travelling to a scheduled mental health appointment when he lost control of his motorcycle on a cur…
48y · Male·Dilated cardiomyopathy with contributing factor of acute renal impairment
David Farlech, a 48-year-old man with Down's Syndrome and intellectual disability living in a group home, died from dilated cardiomyopathy with acute renal impairment. He presented with chest, rib cage and abdominal pain…
68y · Male·Ischaemic heart disease (operated); severe native coronary artery atheroma with …
Brian John Schulze, aged 68, died of ischaemic heart disease (operated) while subject to a Mental Health Act inpatient treatment order at Flinders Medical Centre. He presented with falls, confusion, and agitation followi…
53y · Female·Unable to determine; circumstances suggest death by suicide but body never recov…
Angela Joy Jeffrey, a 53-year-old woman with a long history of depression managed with antidepressants and psychiatric care, disappeared on 1 June 2016 from Bakers Beach, Tasmania. She had experienced a significant mood …
55y · Male·Bronchopneumonia in a man with a healing myocardial infarction
Leon Edward Balshaw, aged 55, died from bronchopneumonia complicating a healing myocardial infarction while in police custody. He was arrested on 25 January 2018 following a domestic dispute and taken to Bairnsdale Regio…
30y · Male·gunshot wound to the head as a result of a police operation
Danukul Mokmool, aged 30, died on 26 July 2017 after being shot by NSW Police at Central Railway Station following a mental health crisis. He was experiencing acute psychosis with paranoid delusions that his family inten…
77y · Female·Pulmonary thromboembolism secondary to deep vein thrombosis of the left leg
A 77-year-old woman with Factor V Leiden thrombophilia and history of PE presented to a rural urgent care centre on 19 April 2017 with shortness of breath and chest pain. She was examined by Dr H. who considered but dism…
47y · Female·Overdose of hydromorphone
A 47-year-old woman died from an intentional overdose of prescribed hydromorphone while residing at a domestic violence refuge. She had a history of depression, previous suicide attempts, and was in crisis following sepa…
18y · Female·Multiorgan failure complicating malnutrition in a female with liver cirrhosis, o…
An 18-year-old female with Down syndrome, autism spectrum disorder, and severe intellectual disability died from multiorgan failure complicating severe malnutrition, non-alcoholic fatty liver disease, and obesity. She pr…
3y · Male·unascertained
A 3-month-old boy died with an unascertained cause after being found unresponsive in his bassinet with a blanket covering his mouth and face. His mother had ongoing heroin use throughout pregnancy and postnatally, concea…
63y · Male·Sepsis in a man with complicated peripheral vascular disease
Hong Tay, a 63-year-old man with extensive peripheral vascular disease, diabetes, and prior amputations, died from sepsis in an aged care facility following a cervical spine fracture sustained in a fall. After conservati…
45y · Female·Hanging
A 45-year-old woman with bipolar affective disorder, borderline personality disorder, anorexia nervosa and depression died by hanging. She had chronic suicidal ideation and was managed in the community by a mental health…
43y · Female·Hypoxic ischaemic brain injury resulting from alcohol and sodium valproate toxic…
43-year-old woman with epilepsy and depression died from hypoxic ischaemic brain injury after ingesting 15g sodium valproate and 750ml vodka. Critical failures occurred across multiple settings: VPIC provided incomplete …
68y · Male·Cardiomegaly
James Kenneth Cowl, a 68-year-old man with severe cardiomyopathy, atrial fibrillation, schizophrenia, and intellectual disability, died suddenly from cardiomegaly while in residential care. An echocardiogram performed sh…
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