45y · Female·Extensive retroperitoneal haemorrhage following bone marrow biopsy procedure wit…
…atosis type 1, essential thrombocytosis, prior cancers, and recent cerebral infarcts on warfarin, underwent bone marrow biopsy at Royal Perth Hospital on 23 November 2004 to investigate her thrombocytosis and exclude leu…
55y · Male·Pneumonia, bone marrow failure and metastatic carcinoma of unknown origin
…going abdominal pain. He deteriorated with respiratory failure from pneumonia, complicated by pancytopenia. Bone marrow biopsy revealed metastatic adenocarcinoma of unknown primary with bone marrow failure. He was transf…
86y · Male·combined effects of acute myeloid leukaemia, acute renal failure and staphylococ…
…ollowing sentencing in 2016, he was seen in November 2016 with suspected myelodysplasia and recommended for bone marrow biopsy, which he declined. By July 2018, his condition had deteriorated acutely with organ failure a…
50y · Male·multi-organ failure due to pancreatitis and generalised varicella zoster virus i…
…les Andrew Tabb, a 50-year-old prisoner with non-Hodgkin's lymphoma (diagnosed 13 years prior, treated with bone marrow transplants), died of multi-organ failure from pancreatitis and disseminated varicella zoster virus …
52y · Female·Unascertained (natural causes)
…n stores, but no definitive diagnosis. Despite comprehensive workup including colonoscopy, gastroscopy, and bone marrow biopsy, the underlying cause remained unclear. She was appropriately transitioned to palliative care…
69y · Male·Waldenstrom's Macroglobulinemia, a type of non-Hodgkin lymphoma
Colin Hay, a 69-year-old man serving a custodial sentence, died from Waldenstrom's Macroglobulinemia (a non-Hodgkin lymphoma) on 21 October 2016 in the Secure Unit Annex of Prince of Wales Hospital. He was diagnosed in J…
44y · Male·Acute myeloid leukemia
A 44-year-old man with acute myeloid leukemia died in St Augustine's secure ward at St Vincent's Hospital on 18 February 2020. He had been under treatment for refractory AML since June 2019, with disease progression desp…
66y · Male·Bronchopneumonia and influenza A complicating cardiac and renal failure associat…
A 66-year-old man with cryoglobulinaemic vasculitis secondary to non-Hodgkin's lymphoma died from bronchopneumonia and influenza A complicating cardiac and renal failure. He developed delirium, agitation and paranoia dur…
58y · Male·Haemophagocytic lymphohistiocytosis, due to or as a consequence of T-cell lympho…
Frank Burrows, a 58-year-old male prisoner, died from Haemophagocytic Lymphohistiocytosis (HLH) secondary to T-cell lymphoma. He presented with non-specific symptoms (fever, sweats, diarrhoea) and was initially discharge…
4y · Male·acute lymphoblastic leukaemia
An Hoang Le Nguyen, a 4-year-old boy, died from acute lymphoblastic leukaemia with CNS involvement. He presented with a 4-day history of abdominal pain, lethargy, fever, and respiratory symptoms at Royal Darwin Hospital …
69y · Female·Multiple organ failure due to secondary haemochromatosis (transfusion-associated…
Mrs Vicki Dow, 69, died from multiple organ failure secondary to iron overload (transfusion-associated haemochromatosis) from treatment of myelodysplastic syndrome. She had declined iron chelation therapy for 19 months d…
72y · Male·Diffuse large B cell lymphoma
Douglas Stott, a 72-year-old prisoner with diffuse large B cell lymphoma, died of natural causes in hospital on 7 January 2021. He had been receiving telehealth oncology consultations while incarcerated but refused in-pe…
17y · Male·Multi-organ failure with terminal fungal sepsis (Aspergillus) on a background of…
Ben Witham, a 17-year-old with acute lymphoblastic leukaemia, died from multi-organ failure with terminal fungal sepsis. The critical issue identified was a substantial delay in investigating acute severe abdominal pain …
61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed
A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…
69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…
Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…
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…
77y · Male·Hypothermia
Raymond Speechley, aged 77 with dementia, absconded from an aged care secure unit on 7 July 2016 and died from hypothermia in bushland. Critical systemic failures at the facility included: failure to identify him as an a…
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