78y · Female·advanced dementia (end stage)
…d dementia (end stage) at Repatriation General Hospital on 23 September 2017. She had Primary Progressive Aphasia diagnosed in 2014 following non-Hodgkin's lymphoma treatment. After admission to RGH on 23 August 2017 wi…
84y · Male·Head and neck injuries sustained in a fall; specifically facial bone fractures a…
An 84-year-old man with primary progressive aphasia and cognitive decline residing in aged care sustained fatal head and neck injuries from a fall on 13 May …
58y · Male·Aspiration pneumonia in a man with a left middle cerebral artery stroke (palliat…
Brian Lench, a 58-year-old man with intellectual disability in DHS residential care, suffered a left middle cerebral artery stroke on 6 October 2011. He developed aspiration pneumonia complicated by acute respiratory dis…
65y · Male·aspiration pneumonia
Roger Alan Gibson, a 65-year-old man with advanced Alzheimer's disease and severe behavioural disturbance, died from aspiration pneumonia at the Roy Fagan Centre. He had been admitted following escalating aggression requ…
73y · Female·fractured neck of femur (operated) on a background of Alzheimer's dementia
Linda Eileen Saberton, aged 73, died from complications of a fractured neck of femur sustained in a fall at her aged care facility, on a background of advanced Alzheimer's dementia. She had suffered two hip fractures wit…
72y · Female·Obstruction of the airways of the neck
…o education about the 33% risk of depression in stroke survivors generally, or the 60% risk in those with aphasia specifically, and were not informed of the doubled suicide risk in the first two years post-stroke. The p…
18y · Male·Aspiration pneumonia in a setting of acquired brain injury from non-accidental h…
…cquired brain injury sustained non-accidentally as an infant. He had severe cerebral palsy, tetraparesis, aphasia, visual impairment, intellectual disability, epilepsy, and gastro-oesophageal reflux. After transitioning…
56y · Male·Basal ganglia haemorrhage with intraventricular extension in the context of moya…
Mr Ho Hai Vu, a 56-year-old with moyamoya disease and history of prior basal ganglia haemorrhages, died from acute basal ganglia haemorrhage with intraventricular extension. He was found unresponsive and vomiting in his …
29y · Female·peritonitis caused by ischaemia of the bowel due to gastrointestinal torsion (tw…
Shona Hookey, a 29-year-old Aboriginal woman with severe intellectual disability and aphasia, died of peritonitis secondary to bowel torsion. Critical failures occurred at multiple levels: carers at…
83y · Male·left middle cerebral artery cerebrovascular accident
An 83-year-old male prisoner died from a left middle cerebral artery stroke on 26 October 2022, seven days after presenting with acute stroke symptoms. Mr Radan had atrial fibrillation and was prescribed dabigatran for a…
64y · Male·Pneumonia secondary to ischaemic cerebrovascular incidents, hypertension, and at…
Yan Jin, a 64-year-old man with history of stroke, hypertension, and atrial fibrillation, was admitted to hospital after a witnessed fall from bed. Despite no fractures, he remained hospitalised for discharge planning gi…
53y · Male·Gastrointestinal haemorrhage complicating recent PEG insertion with stroke as a …
Tan Van Tran, a 53-year-old man with prior stroke causing severe dysphagia, died from gastrointestinal haemorrhage complicating recent PEG insertion. He was admitted with aspiration pneumonia and underwent PEG placement …
82y · Male·bronchopneumonia
Gerald Quinane, an 82-year-old man with intellectual disability living in state-managed residential care, died from bronchopneumonia. He presented with respiratory symptoms and was taken to hospital on 1 March 2014, trea…
61y · Male·Creutzfeldt-Jakob disease
Christopher Raymond Hausler, a 61-year-old man, died from Creutzfeldt-Jakob disease (CJD) at the Royal Adelaide Hospital on 13 March 2018 while subject to a Level 2 Inpatient Treatment Order. He presented with rapidly pr…
62y · Male·multiple co-morbidities including dementia, Parkinson's disease, undernourishmen…
Michael Nelson, 62, died at Westmead Hospital on 3 May 2014 with multiple comorbidities including early-onset dementia, Parkinson's disease, neck dystonia (torticollis), and undernourishment. He presented to ED with inab…
94y · Male·aspiration pneumonia due to stroke following surgery to repair fracture of neck …
A 94-year-old man with dementia died from aspiration pneumonia following a stroke after hip surgery. The stroke and hip fracture resulted from being pushed by another resident with Alzheimer's dementia at an aged care fa…
55y · Female·Plastic bag suffocation
Alison Copeland, aged 55, died by plastic bag suffocation after living with severe physical disability and depression since suffering a subarachnoid haemorrhage in 1995. She had made multiple suicide attempts over 16 yea…
72y · Male·Choking on a food bolus
A 72-year-old man with vascular dementia, stroke history, and dysphagia died from choking on food while being fed by a nurse in aged care. The coroner found the death was preventable due to staff lack of training in safe…
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