67y · Female·Complications of metastatic lung cancer, in a woman with chronic obstructive pul…
Grethe Larsen, a 67-year-old woman with advanced multiple sclerosis, COPD, and metastatic lung cancer, died from complications of her malignancy. She resi…
57y · Female·Deterioration in setting of advanced dementia on a background of down syndrome
A 57-year-old woman with Down syndrome and advanced Alzheimer's dementia died from natural causes following a period of functional decline. She was residing …
47y · Male·Complications of chronic lymphocytic leukaemia in a man with intellectual disabi…
…ty, epilepsy, and chronic lymphocytic leukaemia, died of complications of his leukaemia while residing in supported disability accommodation. He had a longstanding complex medical history including Lennox-Gastaut syndro…
60y · Female·Aspiration pneumonia in the setting of advanced Huntington's disease
A 60-year-old woman with advanced Huntington's disease died from aspiration pneumonia while in specialist disability accommodation. She had…
55y · Female·Complications of metastatic colorectal carcinoma
…d agitation. Palliative care was initiated and she died in October 2019. The coroner found the disability support services provided by Life Without Barriers were reasonable and appropriate. Care staff should have been a…
50y · Male·Advanced Parkinson's disease
A 50-year-old man with advanced Parkinson's disease died of natural causes at Austin Hospital after admission for palliative care managem…
90y · Male·Complications following aspiration of food
…D presentation two days prior for suspected aspiration, he was managed palliatively at his care facility. Support staff appropriately recognised swallowing difficulty, ceased fluid administration, and maintained observa…
59y · Female·Sepsis in a woman with epilepsy, cerebral palsy and haemochromatosis
…l management was reasonable and appropriate throughout. Key lessons include: (1) the importance of formal advanced care planning and Goals of Care discussions in vulnerable patients with complex chronic conditions; (2) e…
64y · Male·undetermined due to advanced decomposition
Bodo Cazimir, a 64-year-old man, died alone at home between May and July 2015. He was found in an advanced state of decomposition, making autopsy inconclusive. A bladder tumour had been identified by his GP in Ja…
61y · Female·Decompensated liver failure - Child's Pugh B cirrhosis secondary to renal failur…
…ital on 6 September 2023 with liver failure, developed sepsis and multi-organ failure, and commenced end-of-life care on 10 September 2023. The coroner found no evidence of inadequate clinical management or care by eithe…
87y · Female·Hypoxic-ischaemic encephalopathy secondary to cardiac arrest, with valvular hear…
An 87-year-old woman died following a CT-guided epidural injection at a private radiology clinic. Although she had undergone the procedure for spinal pain, the radiologist performed an epidural injection at the T12 level…
57y · Male·Aspiration pneumonia complicating locally advanced non-small cell carcinoma of l…
… lung cancer, schizophrenia, epilepsy, and dysphagia, died from aspiration pneumonia complicating locally advanced non-small cell lung carcinoma. His illness was identified in late February 2025 when carers noted deterio…
63y · Male·acute blood loss due to self-inflicted sharp force incisional wounds of the thro…
…rtance of risk assessment during periods of leave from mental health units, particularly around significant life stressors (tooth loss); and paramedic decision-making regarding Advanced Care Directives in acute trauma. T…
38y · Female·Pentobarbital toxicity
A 38-year-old woman with advanced Huntington's disease died from pentobarbital toxicity after intentional ingestion. She had progressive ne…
47y · Male·Pneumonia (1(a)), Motor neurone disease (1(b))
Raymond Cassar, a 47-year-old man with motor neurone disease requiring ventilatory support, died of pneumonia at a disability accommodation service. He had been diagnosed with a chest infection on…
56y · Female·Complications of motor neuron disease
…man with motor neuron disease diagnosed in 2014, died from complications of her disease while residing in supported disability accommodation. She had a PEG tube for feeding and required nocturnal ventilation. An advance…
41y · Female·Metastatic oesophageal carcinoma
Catherine Myee Drinkwater, 41, died of metastatic oesophageal cancer diagnosed in June 2022. She lived in Supported Disability Accommodation as an NDIS participant with multiple comorbidities including Asperger's syndro…
2y · Male·Hypoxic-ischaemic encephalopathy
…5 minutes before retrieval. Resuscitation commenced at scene around 15-20 minutes after delivery. Despite advanced life support, Baby M suffered irreversible hypoxic-ischaemic encephalopathy from prolonged oxygen depriva…
51y · Female·Complication of Parkinson's disease
…ruction and subsequently refused medications. By July, she was on home palliative care with daily nursing support and commenced on a syringe driver for comfort on 31 July 2025. The coroner found no evidence that care pr…
67y · Male·hypoxic respiratory failure in the setting of pneumonia, pulmonary embolism and …
…at Lyell McEwin Hospital from hypoxic respiratory failure complicating pneumonia, pulmonary embolism, and advanced hepatocellular carcinoma. He had been imprisoned at Yatala Labour Prison and received significant medical…
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