3,729 results
66y · Male·blunt trauma head and chest
A 66-year-old man with advanced heart and lung disease attended hospital with calf pain investigated for DVT post-COVID vaccination. He was given anticoagulation and discharged. Despite appearing unwell and unsteady to h…
61y · Male·metastatic oesophageal neuroendocrine carcinoma
Terrence Wells, a 61-year-old prisoner, died from metastatic oesophageal neuroendocrine carcinoma in December 2018. Cancer was diagnosed in April 2018 after he reported difficulty swallowing, which was initially attribut…
67y · Male·Fulminant liver failure
A 67-year-old man presented to his GP with discoloured urine. Blood tests revealed acute liver toxicity but critical results were communicated via facsimile, with unclear timing of GP's review. The patient deteriorated r…
63y · Female·Sepsis complicating cellulitis following skin cancer excision and skin graft pro…
A 63-year-old woman died from sepsis complicating cellulitis following elective skin cancer excision and skin graft performed in a general practitioner's clinic. The lesion was a squamous cell carcinoma (invasive Bowen's…
73y · Female·Unknown due to decomposition
Mrs Chrupalo, a 73-year-old woman with physical disability, cognitive impairment and alcohol dependency, was discharged from Dubbo Base Hospital on 8 July 2015 against medical advice despite being bedbound and dependent …
Male·Unrecognised pulmonary hypertension in a setting of unsafe sleeping conditions
Jack Loh, a 6-month-old boy, died from unrecognised pulmonary hypertension while in unsafe sleeping conditions at a family day care centre. Jack was placed prone (face down) in an undersized bassinet with loose bedding m…
29y · Male·ligature compression of the neck (hanging)
Brett Ashley Duturbure, aged 29, died by suicide via hanging at Wyndham Work Camp on 14 November 2019. The coroner identified critical systemic failures in the Department of Justice's management of his care. The Departme…
50y · Male·Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (t…
A 50-year-old man died from tracheostomy site haemorrhage 36 days after laryngectomy for recurrent laryngeal cancer. He lived alone post-discharge with a MePACS personal alarm system and home nursing visits. When bleedin…
Male·Combined effects of multiple blunt force injuries and the effects of fire (Craig…
Craig Whitall, a 49-year-old on methadone maintenance therapy, drove erratically on the Princes Highway after leaving hospital on Boxing Day 2017, colliding head-on with the Falkholt family vehicle, killing five people. …
44y · Female·Ischemic heart disease due to complete blockage of left anterior descending coro…
A 44-year-old woman presented with acute chest pain and troponin elevation. Coronary angiography revealed only a 30% non-obstructive lesion in the left anterior descending artery. She was discharged on aspirin alone with…
5y · Male·Sudden Unexpected Death in Infancy (SUDI +0); exact cause unascertained
A 5-month-old premature infant with low birth weight died suddenly and unexpectedly at home. Toxicological testing revealed the presence of frusemide (a diuretic medication) in his blood and other samples, which should n…
4y · Unknown·Drowning
A 4-year-old boy drowned in a resort pool during a family birthday party on 13 December 2020. Despite wearing a buoyancy vest initially, he removed it to use water slides more freely. While approximately 8 adults were pr…
20y · Male·Multiple injuries from fall from height
Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, disclosed suicidal ideation to a prison psychologist. This led to his placement on a Risk Intervention Team management plan requiring…
20y · Male·Multiple injuries from fall from height
Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, died from multiple injuries after impulsively jumping an 8-metre wall at a hospital ambulance bay on 5 November 2019. He was in custo…
38y · Male·cardiac arrhythmia with acute circulatory failure in a man with acute drug effec…
Ohm Sathitpittayayudh, aged 38, died in custody at Karnet Prison Farm from cardiac arrhythmia with acute circulatory failure after ingesting 5F-ADB (Kronic), a synthetic cannabinoid. He had exemplary prison behaviour, go…
55y · Female·acute myocardial infarction due to right coronary artery thrombosis
A 55-year-old woman presenting to the emergency department with 24 hours of chest pain, arm pain, sweating and vomiting was discharged without an ECG or troponin measurement. She had an abdominal CT suggesting cholecysti…
1y · Male·Global cerebral ischaemic injury following cardiorespiratory arrest of unknown c…
A 22-month-old boy died from global cerebral ischaemic injury following cardiorespiratory arrest of unknown cause in the setting of detected methylamphetamine exposure. He had multiple healing traumatic injuries (rib fra…
79y · Male·Complications of ischaemic heart disease
HV was a 79-year-old man who died in custody at Port Phillip Prison from complications of ischaemic heart disease. He had significant cardiac history including previous myocardial infarction, atrial fibrillation, pulmona…
43y · Female·Multisystem organ failure and hypoxic/ischaemic encephalopathy following anaphyl…
Peta Hickey, a 43-year-old company executive with no cardiac history, died from anaphylaxis to CT coronary angiogram contrast after her employer commissioned an inappropriate screening program. The referral lacked clinic…
90y · Male·Sepsis in the setting of cachexia in a man with multiple comorbidities
Ronald Jelbert, a 90-year-old man with moderate intellectual disability living in a disability group home, was admitted to hospital on 21 December 2019 with sepsis suspected secondary to urinary tract infection, colonic …
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