91y · Female·Complications of pelvic fractures sustained in a fall
…otics for presumed pneumonia. She suffered cardiac arrest shortly after antibiotic administration and died. Post-mortem CT revealed pelvic fractures missed on initial imaging. Key clinical lessons: the initial hip x-ray …
76y · Male·complications of acute myeloid leukaemia
…p including laparoscopic cholecystectomy, the underlying haematological malignancy was not identified until post-mortem bone biopsy. He deteriorated rapidly in ICU and died on 19 August 2021. The coroner found that custo…
87y · Female·acute intracranial haemorrhage
…r a Mental Health Act detention order. She was on warfarin for DVT management when she collapsed. A CT head scan was performed but images could not be viewed due to a GE systems outage, and she died before imaging result…
67y · Female·bronchopneumonia complicating disseminated pulmonary large cell carcinoma with r…
…ver, adrenal glands, and brain. She developed bronchopneumonia and died despite broad-spectrum antibiotics. Post-mortem also identified recent myocardial infarction. The coroner found no grounds for criticism of medical …
71y · Female·Haemothorax and haemopericardium secondary to ruptured dissecting aneurysm of th…
…vernight and died from a ruptured thoracic aortic dissection with massive haemothorax and haemopericardium. Post-mortem review identified that a pre-contrast CT scan before the contrast study might have detected early mu…
76y · Female·Undetermined (natural causes)
… under a Mental Health Act order. She underwent gastroscopy for diagnostic purposes, could not be extubated post-procedure, and was admitted to ICU with type 2 respiratory failure. Despite supportive care including non-i…
83y · Male·Metastatic oesophageal adenocarcinoma
George Iles, an 83-year-old prisoner, died from metastatic oesophageal adenocarcinoma. He had multiple comorbidities (asthma, hypertension, heart disease) and experienced falls and deterioration during incarceration. In …
65y · Male·Metastatic disease with gastrointestinal primary (adenocarcinoma)
Ronald Nieuwenhuis, a 65-year-old man with intellectual disability residing in supported accommodation, presented to hospital in January 2025 with abdominal pain and was found to have metastatic adenocarcinoma of gastroi…
73y · Male·complications of lung carcinoma in a man with multiple comorbidities
John William Macfie, a 73-year-old man with extensive medical comorbidities (COPD, ischemic heart disease, prior CABG surgeries, cardiac stents, hypertension, hyperlipidemia) and a chronic smoking history, died from comp…
62y · Male·Head injury (acute subdural haemorrhage and fractured skull)
A 62-year-old man with schizophrenia, lung cancer, and seizure history was an involuntary patient at Broadmeadows Psychiatric Unit. While supervised in the courtyard, he suddenly stopped walking then fell backwards, stri…
23y · Female·Arrhythmia of unknown aetiology
…m. The coroner found her psychiatric treatment was appropriate and medications did not contribute to death. Post-mortem excluded hypoglycaemia, pulmonary emboli and aspiration as causes. Expert toxicology review found no…
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…
17y · Female·Acute Lymphocytic Meningitis and Focal Myocarditis
…er GP. On 10 January 2009, she suffered a cardiac arrest at home and was transferred to ICU where she died. Post-mortem revealed acute lymphocytic viral meningitis with concurrent focal myocarditis, an unusual combinatio…
35y · Female·Global cerebral ischaemic injury in the setting of post caecal resection for col…
…nderwent left hemicolectomy for colorectal cancer at Albury Base Hospital. She suffered a suspected seizure post-operatively, failed to regain consciousness, and was transferred to St Vincent's Hospital where imaging rev…
52y · Female·Hypoxic brain injury due to hypotension in a woman with documented electrocardio…
…pulmonary resuscitation. She developed refractory seizures and hypoxic brain injury, dying four days later. Post-mortem examination revealed coronary artery disease, mitral valve prolapse, and multiple pulmonary emboli. …
25y · Male·cerebral craniopharyngioma
…er reporting his headache had improved, though nursing notes suggested pain remained at 6-7/10 at 06:25hrs. Post-discharge, he attended another GP who recommended CT scan but no urgent indication was documented. The appo…
47y · Male·Metastatic mesothelioma
James John Wilson, a 47-year-old man imprisoned at Port Phillip Prison, died from metastatic mesothelioma on 5 May 2019 at St Vincent's Hospital. He was diagnosed with epithelioid mesothelioma in January 2019 following C…
85y · Male·Intracranial haemorrhage in the setting of a fall in a man with multiple comorbi…
…iple comorbidities suffered a fall at home and was transported to hospital with stroke symptoms. A CT brain scan revealed subtle subarachnoid haemorrhage (traumatic), but the VST consultant neurologist missed this findin…
72y · Male·Subarachnoid haemorrhage in a man with coronary arteriosclerosis
Ilija Kocovski, a 72-year-old man with a history of ischaemic heart disease, presented to Royal Perth Hospital Emergency Department on 22 October 2000 with chest pain, nausea, vomiting, and headache after arriving in Per…
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…
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