383 results
88y · Male·Sepsis of unknown aetiology in a man with ischaemic cardiomyopathy and other med…
An 88-year-old man incarcerated at Hopkins Correctional Centre died from sepsis of unknown aetiology with ischaemic cardiomyopathy. He developed pneumonia while in custody, was admitted to Ararat Hospital twice in late J…
58y · Male·Aspiration pneumonia, in the setting of epilepsy and Down's syndrome
John Rose, aged 58, with Down's syndrome and epilepsy, died from aspiration pneumonia at Sunshine Hospital. He was admitted following seizures and developed aspiration pneumonia during his hospital stay, which did not re…
57y · Male·Combined effects of aspiration pneumonia and epilepsy (with cerebral palsy as un…
Mr Vincenzo Mario Chiarello, a 57-year-old man with cerebral palsy, intellectual disability, and epilepsy living in specialist disability accommodation, died from combined aspiration pneumonia and epilepsy complicated by…
40y · Female·Sepsis secondary to ureteritis, pyelonephritis and aspiration pneumonia with a c…
A 40-year-old woman with cerebral palsy, autism, and schizoaffective disorder living in specialist disability accommodation died from sepsis secondary to ureteritis, pyelonephritis, and aspiration pneumonia. She had sust…
44y · Male·cardiogenic shock, on a background of severe tricuspid valve regurgitation, seve…
Jeffrey Blundell, a 44-year-old man with severe intravenous drug use history, died from cardiogenic shock secondary to severe tricuspid valve regurgitation caused by infective endocarditis from non-sterile injection prac…
75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis
A 75-year-old woman with chronic pain and previous staphylococcal infections presented to Glen Innes District Hospital with a swollen, warm right knee 10 days after a corticosteroid injection. Junior doctor Dr M. appropr…
51y · Male·Aspiration pneumonia in a man with severe scoliosis and cerebral palsy
A 51-year-old man with severe scoliosis and cerebral palsy died from aspiration pneumonia. He had a documented history of aspiration risk requiring monitoring while drinking. During admission for drowsiness and hypotherm…
12y · Female·Hypoxic ischaemic encephalopathy complicating an aortic root abscess (operated) …
A 12-year-old Aboriginal girl with a bicuspid aortic valve and autism spectrum disorder presented with a week of fever and non-specific symptoms (cough, vomiting, abdominal pain, chest pain) to a rural hospital. Despite …
Female·Betty: cardiac arrhythmia complicating heart failure due to consequences of past…
This inquest examined three deaths of young Aboriginal women from Doomadgee (ages 18, 37, and 17) from rheumatic heart disease (RHD) complications between September 2019 and September 2020. All three deaths were preventa…
84y · Male·Urinary tract infection in a man with Parkinson's disease
An 84-year-old man with Parkinson's disease and dementia died from urinary tract infection with sepsis while incarcerated. On 3 November 2021, he developed fever and confusion; antibiotics were commenced. The following m…
63y · Female·undetermined (natural causes); COVID-19 infection likely contributory
Gillian Burgess, a 63-year-old non-verbal autistic woman with intellectual disability, chronic kidney disease and heart disease, died in a Specialist Disability Accommodation facility. She was diagnosed with COVID-19 on …
56y · Male·Complications of clostridium difficile and malnutrition in the setting of cerebr…
Mr C was a 56-year-old man with cerebral palsy and acquired brain injury who died from complications of Clostridioides difficile infection and malnutrition. He was admitted to hospital on 21 January 2022 with diarrhoea, …
60y · Male·sepsis/leg cellulitis with peripheral oedema and congestive cardiac failure in t…
Andrew Leader, a 60-year-old man with treatment-resistant schizophrenia, emphysema, COPD, chronic hyponatraemia, and heart failure, died of sepsis from leg cellulitis with peripheral oedema and congestive cardiac failure…
51y · Male·COVID-19 pneumonia
Suong Van Nguyen, a 51-year-old worker at a chicken processing plant, died from COVID-19 pneumonia during home isolation in August 2020. He tested positive on 31 July, reported shortness of breath on 2 August, then becam…
84y · Male·Respiratory failure complicating hospital acquired pneumonia following surgical …
An 84-year-old man died from respiratory failure due to hospital-acquired pneumonia following surgery for recurrent mandibular squamous cell carcinoma. Key clinical lessons: (1) Advanced Care Plans (ACPs) must be activel…
59y · Male·Aspiration pneumonia and non-ST elevation myocardial infarction in a man with in…
A 59-year-old man with intellectual disability, autism, and visual impairment died from aspiration pneumonia and non-ST elevation myocardial infarction complicated by COVID-19. He presented to the ED febrile with elevate…
7y · Female·multiorgan failure due to fulminant sepsis (Streptococcus pyogenes)
7-year-old Aishwarya Aswath Chavittupara died from multiorgan failure due to fulminant sepsis (Streptococcus pyogenes) after approximately 90 minutes in Perth Children's Hospital emergency department. She presented with …
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
Maarouf El-Cheikh, a 57-year-old man with splenectomy history, presented to Calvary Hospital ED with sepsis on 21 March 2016 and died 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadeq…
3y · Male·Disseminated Staphylococcus aureus infection
A 3-year-old Aboriginal boy died from disseminated Staphylococcus aureus infection with sepsis. He presented to a remote clinic on 10 April with fever and dizziness, then returned on 13 April with irregular fever, lethar…
59y · Male·complications of viral liver cirrhosis with hepatocellular carcinoma
Mervyn Morgan, aged 59, died from complications of hepatocellular carcinoma arising from cirrhosis while in prison custody. Critical failures included: delayed monitoring of known liver cirrhosis (no ultrasound despite M…
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