41y · Male·Cardiomyopathy in a setting of acute abdomen
…teriorated despite ICU care. The coroner found death resulted from cardiomyopathy in the setting of acute abdomen of unknown aetiology. No medical mismanagement was identified. The exact cause of the acute abdomen remai…
88y · Female·Complications of a pedestrian accident including subarachnoid haemorrhage, subdu…
An 88-year-old woman with multiple comorbidities (diabetes, ischaemic heart disease, cardiomyopathy) was struck by a reversing vehicle at low speed, sustaining subarachnoid haemorrhage, subdural haemorrhage, and fracture…
76y · Male·Extensive small bowel infarction caused by superior mesenteric artery thrombus
A 76-year-old man presented to ED with sudden onset left-sided abdominal pain, vomiting and bowel incontinence. Initial CT imaging was reassuring. However, mesenteric ischaemia—characterised by severe pain without signif…
63y · Male·Complications of Metastatic Non Small Cell Lung Cancer
…om complications of metastatic non-small cell lung cancer. He was diagnosed in November 2012 following a CT scan investigating chest symptoms and weight loss. His care involved coordination between St Vincent's Hospital,…
75y · Male·Multiorgan dysfunction syndrome complicating anastomotic leak following hemicole…
…vestigate an intra-abdominal cause until day 8 post-surgery, despite clinical indicators of infection. A CT scan on day 10 revealed free fluid but was not acted upon promptly; transfer to St Vincent's occurred on day 10,…
61y · Male·Multiorgan failure, due to, or as a consequence of metastatic lung cancer (suspi…
Shane Anthony May, a 61-year-old prisoner, died of multiorgan failure secondary to metastatic lung cancer after 44 days in custody. He presented with COVID-19 symptoms on reception, then developed progressive respiratory…
68y · Male·Lung cancer
Daniel McQuilken, a 68-year-old man in immigration detention, died from metastatic lung cancer. His lung cancer diagnosis was made while detained, likely related to his significant smoking history and prior asbestos and …
86y · Female·Metastatic ovarian cancer (high-grade serous carcinoma)
An 86-year-old woman serving a life sentence died of metastatic ovarian cancer in palliative care. After diagnosis in April 2023, treatment was appropriately limited to symptom management given her advanced dementia, mak…
71y · Female·pneumonia following cervical spine fracture sustained in motor vehicle collision
…ising and institutional guidelines requiring radiology for trauma patients over 65 years; (3) a CT shoulder scan failed to detect the cervical fracture; (4) ICU staff did not diagnose the underlying injury despite clinic…
60y · Male·multi-organ failure due to injuries sustained in motor vehicle accident, specifi…
A 60-year-old Aboriginal man with significant comorbidities (cardiomyopathy, cirrhosis, renal failure, diabetes) presented to ED following a motor vehicle accident at low speed. Despite chest imaging showing pleural effu…
59y · Male·Disseminated carcinoma on a background of emphysema
Robert Fullerton, a 59-year-old Aboriginal man from Palm Island, died from disseminated carcinoma while remanded in custody at Townsville Correctional Centre. He presented with abdominal pain on 5 December 2018, was diag…
28y · Male·Traumatic intracranial haemorrhage sustained in an unwitnessed fall
A 28-year-old man died from traumatic intracranial haemorrhage following an unwitnessed fall at his apartment building. He had been heavily intoxicated (blood alcohol 0.27 g/100mL, cocaine positive) at a social event and…
35y · Male·intraperitoneal haemorrhage from an anastomotic leak from a transplanted renal a…
…ansplant team's availability; no senior consultant personally examined Luke or actively pursued critical CT scan results. Although early senior involvement might not have changed the ultimate outcome, the case highlights…
65y · Male·Middle cerebral artery stroke in a man with multiple medical co-morbidities
Winfried Medenbach, a 65-year-old man with tuberous sclerosis, severe intellectual disability, epilepsy, and history of bowel complications, died from a middle cerebral artery stroke. He had been admitted to hospital in …
63y · Male·Aspiration pneumonia in the setting of functional decline in a man with an intel…
A 63-year-old man with intellectual disability, cerebral palsy, dysphagia, and COPD died from aspiration pneumonia following functional decline. He had a three-month hospital admission with multiple complications includi…
82y · Male·Acute myocardial infarction caused by ischaemic heart disease
Francis Sawle, an 82-year-old man in custody, died of acute myocardial infarction due to ischaemic heart disease while an inpatient at Prince of Wales Hospital. He had significant comorbidities including severe triple ve…
82y · Male·sepsis due to faecal peritonitis due to suture failure of bowel anastomosis foll…
…normal white cell count, afebrile). His polycythaemia and advanced age likely compromised wound healing. CT scan eventually revealed contained leak with gas; drainage was attempted but laparotomy showed extensive anastom…
81y · Male·aspiration of gastric contents complicating disseminated moderately differentiat…
Graham Joseph Butson, aged 81, died from aspiration of gastric contents complicating undiagnosed metastatic lung cancer with brain metastases. He presented with confusion, agitation and atrial fibrillation; a lung mass w…
63y · Male·Bronchopneumonia in a man with cholangitis due to choledocholithiasis
Robert James Wright, a 63-year-old man with intellectual disability living in supported accommodation, died from bronchopneumonia complicated by cholangitis due to gallstone obstruction. He presented with weight loss and…
72y · Male·Aspiration pneumonia and small bowel obstruction secondary to metastatic bowel c…
Patrick Barry, a 72-year-old man with intellectual disability, severe dysphagia, and metastatic bowel cancer, died from aspiration pneumonia and small bowel obstruction. He had recurrent respiratory tract infections and …
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