66y · Male·metastatic adenocarcinoma (palliated) from an unidentified primary tumour
…arkable but CT imaging identified mediastinal lymphadenopathy prompting urgent transfer to hospital and bronchoscopy, which revealed stage 4 metastatic adenocarcinoma. He declined radiotherapy due to requiring transfer t…
73y · Male·Lung cancer (squamous cell carcinoma)
…aging did not affect outcome. At Princess Alexandra Hospital, palliative care was promptly engaged with bronchoscopy confirming terminal squamous cell carcinoma. The coroner found no missed diagnostic opportunities, no o…
20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…
…ugust 2020, 13 days later, his tracheostomy tube became dislodged. Clinical staff performed unnecessary bronchoscopy, misinterpreting findings as a partial obstruction rather than recognising complete dislodgement. Criti…
87y · Male·Endobronchial and pulmonary haemorrhage secondary to pneumonia complicating chro…
An 87-year-old man with atrial fibrillation on warfarin underwent elective bronchoscopy for suspected lung lesion. The admitting respiratory team incorrectly documented a mechanical aortic va…
45y · Male·abdominal sepsis on a background of metastatic lung carcinoma
… presented with respiratory symptoms in January 2019, was diagnosed with terminal lung cancer following bronchoscopy, and received radiotherapy. In February, he developed acute abdominal pain from small bowel perforation…
52y · Female·haemorrhage from a tracheal-innominate artery fistula complicating a tracheostom…
…ved bleeding (3mls) was ambiguous and could represent minor stoma bleeding rather than herald bleeding. Bronchoscopy, angiography, and other investigations would have low diagnostic yield. The coroner recommended enhance…
63y · Female·Escherichia coli septicaemia in a lady with multiple comorbidities
… E. coli septicaemia with multiple comorbidities. She presented with respiratory symptoms and underwent bronchoscopy. On discharge day, she deteriorated with fever, altered consciousness, and hypotension. A MET call was …
23y · Male·aspiration of blood due to stab wound to trachea
…. Expert review identified that penetrating neck wounds warrant surgical evaluation and imaging (X-ray, bronchoscopy) regardless of initial appearance, particularly in intoxicated patients where assessment is unreliable.…
60y · Male·bronchopneumonia as a result of or secondary to cerebral haemorrhage; contributi…
Wayne Barry Matschoss, a 60-year-old man with significant medical comorbidities including cardiac disease, epilepsy, chronic bronchitis and bronchiectasis, died in custody at Rockhampton Base Hospital from bronchopneumon…
74y · Male·Hospital acquired pneumonia complicating chronic lung disease
David Maynard, 74 years old, died from hospital-acquired pneumonia complicating chronic lung disease. He was admitted to Royal Melbourne Hospital in July 2016 with chest pain and delirium attributed to hyponatraemia and …
56y · Male·disseminated malignancy – known non-small cell carcinoma of lung
Colin George Graham, a 56-year-old Aboriginal man with severe COPD and lung cancer, died of disseminated non-small cell carcinoma while in prison custody receiving palliative care. The coroner found his medical care was …
51y · Male·Hyperthermia of unknown cause in a man with cardiac hypertrophy; chronic obstruc…
Arthur Andrianakis, 51, died from hyperthermia of unknown cause with cardiac hypertrophy and COPD. He presented to hospital with respiratory distress following police custody for assaulting his mother. Initial diagnosis …
34y · Female·Pneumonia in a woman with intellectual disability and asthma
Simone Grigg, a 34-year-old woman with intellectual disability and asthma, died from pneumonia. She was living in DHHS supported accommodation and attending Amicus day services. On 21 November 2017, she developed respira…
69y · Male·metastatic squamous cell carcinoma of the lung with chronic obstructive lung dis…
Barry John Matthews, aged 69, died of metastatic squamous cell carcinoma of the lung with chronic obstructive lung disease at an aged care facility while subject to a section 32 detention order. He had undergone chemothe…
78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…
78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). T…
40y · Male·Aspiration pneumonia
Alexander Cameron, a 40-year-old man with complex neurodevelopmental, neurological and psychiatric disorders including epilepsy, autism, and previous neuroleptic malignant syndrome (NMS), died from aspiration pneumonia f…
44y · Male·End stage non-small cell lung carcinoma
Victor Courtney, aged 44, died from end-stage non-small cell lung carcinoma with hepatic metastases while incarcerated at Wolston Correctional Centre. He was diagnosed with lung cancer in November 2012 after presenting w…
56y · Male·aspiration pneumonitis secondary to airways obstruction from squamous cell carci…
Edgar Forrester, a 56-year-old Aboriginal man, died of aspiration pneumonitis secondary to oesophageal squamous cell carcinoma with metastases while in custody. He presented with progressive dysphagia from September 2019…
54y · Male·Complications of cervical spinal stenosis treated with cervical laminectomy and …
Geoffrey Power, aged 54, with severe intellectual disability, blindness, and perinatal hypoxic-ischemic brain injury, underwent indicated cervical laminectomy and fusion for cervical stenosis. Post-operatively, he self-r…
45y · Male·severe chronic obstructive pulmonary disease
Troy Michael Conley, aged 45, died from severe chronic obstructive pulmonary disease (COPD) while imprisoned. He had developed progressive lung disease from occupational exposure to gyprock dust, intravenous drug use (ta…
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