530 results
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…
54y · Male·metastatic small cell lung cancer
Manuel Katsaros, aged 54, died from metastatic small cell lung cancer while in custody at Prince of Wales Hospital Annex receiving palliative care. The coroner found no systemic deficiencies or clinical errors. The patie…
59y · Female·Complications of Trisomy 21
Catherine Mary Lyons, aged 59 with trisomy 21 and moderate intellectual disability, died from complications of her underlying condition. She presented with respiratory tract infection symptoms on 8 December 2022 and was …
27y · Male·Injuries sustained in motor vehicle collision (driver)
Jackson Eales, 27, died in a motor vehicle collision at an intersection when truck driver Gerard Voss failed to stop at a stop sign in December 2016. The coroner found it highly probable Voss had undiagnosed severe obstr…
43y · Female·Complications of obesity including cardiomegaly
Katrina Jane Cervasio, a 43-year-old woman with intellectual disability, obesity, sleep apnoea, and cerebral palsy, died from complications of obesity including cardiomegaly while living in a disability services group ho…
75y · Male·complications of metastatic prostate cancer and end-stage chronic obstructive pu…
Frank Kenneth Major, a 75-year-old prisoner with metastatic prostate cancer and end-stage COPD, died of natural causes in October 2021. The coroner found his overall medical care during incarceration was excellent and co…
83y · Female·Acute on chronic renal failure secondary to infectious exacerbation of chronic o…
An 83-year-old woman with chronic obstructive pulmonary disease and chronic renal failure died from acute-on-chronic renal failure complicated by infectious exacerbation of COPD. She presented to hospital on 13 October 2…
70y · Male·ischaemic and valvular heart disease with chronic pulmonary disease being a sign…
Barry Faulkner, aged 70, died of ischaemic and valvular heart disease with chronic pulmonary disease while in lawful custody at Long Bay Correctional Complex on 25 January 2020. He suffered a sudden cardiac arrest while …
61y · Female·Diffuse alveolar damage in a woman with restrictive lung disease following catar…
A 61-year-old woman with severe restrictive lung disease, obesity, cardiac failure, and diabetes underwent cataract surgery at a private day surgery centre on 13 August 2018. She was unable to lie flat and became hypoxic…
43y · Female·Complications of morbid obesity, including progressive respiratory and cardiac f…
Nicole Abbott, 43, died from complications of morbid obesity (BMI 54.4) including progressive respiratory and cardiac failure, exacerbated by smoking and obstructive sleep apnoea. She was subject to a Psychiatric Treatme…
64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …
Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart fai…
90y · Female·acute bronchopneumonia caused by Staphylococcus aureus
Ruth McKay, 90, died of acute bronchopneumonia after accessing the external courtyard of the Memory Support Unit (MSU) at an aged care facility undetected in the early morning of 17 January 2015. She was found under a st…
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…
61y · Male·Complications of metastatic adenocarcinoma
JM, a 61-year-old man incarcerated at Long Bay Correctional Centre, died from complications of metastatic adenocarcinoma (stage 4 lung cancer with liver lesions). He was diagnosed in February 2022 after presenting to Wag…
68y · Female·Complications of a fall with contributing factors of respiratory failure, respir…
Irene Charlish, a 68-year-old woman with longstanding schizoaffective disorder and multiple comorbidities, fell at her residential facility on 6 June 2017, sustaining a pneumothorax and rib fracture. She was admitted to …
79y · Female·medication related cardiac arrest (verapamil and propranolol) in a patient with …
Mrs Patricia Croxon, a 79-year-old admitted with community-acquired pneumonia, died from medication-related cardiac arrest caused by verapamil and propranolol. The verapamil was charted in immediate release form when she…
41y · Male·Cardiomegaly and Coronary Artery Disease with significant contributing condition…
Jay Crich, a 41-year-old man in custody at Clarence Correctional Centre, died of cardiomegaly and coronary artery disease with emphysema and obesity as significant contributing conditions. He was discovered unresponsive …
36y · Male·Metastatic non-seminomatous germ cell tumour
Andrew McNeil, a 36-year-old man with cerebral palsy and intellectual disability, died from metastatic non-seminomatous germ cell testicular cancer with extensive lung metastases. He was initially presented with suspecte…
75y · Male·Complications of multiple cardiac and respiratory comorbidities
A 75-year-old man with multiple cardiac and respiratory comorbidities died in prison from complications of his underlying conditions. He had pulmonary arterial hypertension, right ventricular failure, chronic lung diseas…
71y · Male·End-stage chronic obstructive pulmonary disease and atherosclerotic heart diseas…
Colin Albert Winter, a 71-year-old prisoner who died from end-stage COPD and atherosclerotic heart disease, received comprehensive medical care during 33 years of incarceration at Casuarina Prison. Key clinical lessons i…
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