61y · Female·Diffuse alveolar damage in a woman with restrictive lung disease following catar…
… 61-year-old woman with severe restrictive lung disease, obesity, cardiac failure, and diabetes underwent cataract surgery at a private day surgery centre on 13 August 2018. She was unable to lie flat and became hypoxic …
22y · Female·Drowning secondary to epileptic seizure
Emily Catherine Stein, aged 22, died by drowning in Cataract Gorge on 25 January 2022. She had recently been diagnosed with epilepsy in May 2021, which was unstable a…
68y · Female·Anaphylaxis in a woman with atherosclerotic cardiovascular disease and emphysema
A 68-year-old woman with severe COPD and undiagnosed atherosclerotic heart disease underwent cataract surgery at Northam Hospital. Post-operatively, she was prescribed Diamox (acetazolamide), a sulphonamide …
64y · Male·end-stage interstitial lung disease
Robert Edwin Collins, aged 64, died in Yatala Labour Prison from end-stage interstitial lung disease. He had advanced pulmonary fibrosis, recurrent pneumonia, obesity, and poor mobility. Following hospitalisation at Roya…
72y · Male·Unascertained natural causes
John James Taylor, a 72-year-old man with Fragile X Syndrome and multiple comorbidities including atrial fibrillation, hypercholesterolaemia, and hypertension, was found deceased in his supported disability accommodation…
82y · Male·Complications of atherosclerotic heart disease with atrial fibrillation in a man…
…l dependence who lived independently until June 2012, when he was admitted to Austin Hospital following a cataract operation with deteriorating mental state. In August 2012, he was transferred to Kingston Centre's Biala …
74y · Male·Ischaemic heart disease in association with coronary artery atherosclerosis
Mr Harris, a respected Aboriginal elder aged approximately 74 years, died of ischaemic heart disease with coronary artery atherosclerosis while travelling bush alone on 2 February 2010. He bogged his vehicle, attempted u…
54y · Male·Open finding - manner and cause undetermined
Fred Jackamora, an Aboriginal man in his mid-50s, disappeared from Kalumburu Mission on 9 November 1983 while attempting to walk approximately 350 kilometres to Mount Elizabeth Station to visit relatives. He was last see…
84y · Male·advanced atherosclerotic coronary vascular disease
John Harold Tunks, an 84-year-old man, died of advanced atherosclerotic coronary vascular disease with contributing emphysema from lifelong smoking. He lived alone despite documented cognitive impairment and functional d…
Male·Hanging
…th, particularly failing eyesight affecting his work as an opal cutter. He had been living with bilateral cataracts, possible diabetes, and possible bowel cancer concerns. The coroner was unable to definitively establish…
84y · Male·haemoperitoneum due to ruptured abdominal aortic aneurysm
Bernard Greenwell, an 84-year-old male, died from rupture of an abdominal aortic aneurysm (AAA) while in custody at Cessnock Correctional Centre. He experienced sudden-onset severe left groin pain at 11:30am on 25 April …
Unknown·Multiple blunt injuries sustained in motor vehicle crash
…ond to the clearly visible, stationary truck despite good visibility, weather and road conditions. Recent cataract surgery and night driving were investigated but discounted as significant contributors. The coroner noted…
68y · Male·Multi-organ failure due to gram-negative sepsis on a background of recent myocar…
A 68-year-old male prisoner with multiple comorbidities (diabetes, end-stage renal failure, COPD, morbid obesity) presented with acute myocardial infarction and underwent coronary artery bypass grafting. Post-operatively…
66y · Female·aspiration pneumonitis and gangrenous necrosis of both feet
A 66-year-old woman with untreated rheumatoid arthritis, severe lower limb cellulitis with gangrenous necrosis, and a personality disorder died from aspiration pneumonitis. She had progressive immobility, lived on a couc…
Male·Avulsion of the brain stem and upper cervical spinal cord suffered when struck b…
… eyesight (visual acuity 6/36 in both eyes, below the safe driving threshold of 6/12) caused by bilateral cataracts. Critically, four medical practitioners, including ophthalmologists, knew of her unfitness to drive but …
19y · Female·asphyxiation
A 19-year-old university student with chronic bilateral uveitis presented to university counselling with depression. She disclosed detailed written suicide plans (helium asphyxiation) to the Head of Counselling, who appr…
81y · Male·Acute myocardial infarction in association with coronary artery atherosclerosis
Robert Charles Bropho, an 81-year-old Aboriginal man imprisoned since 2008 with severe medical comorbidities including insulin-dependent diabetes, hypertension, chronic renal failure, and severe ischaemic heart disease, …
20y · Male·multiple injuries sustained in a motor vehicle accident (cyclist)
A 20-year-old elite cyclist was struck from behind and killed by a motor vehicle driven by a 73-year-old man with previously undiagnosed hemianopia (loss of peripheral vision to the left). The driver had struck another c…
2y · Male·multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndro…
A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poo…
69y · Female·bronchopneumonia complicating intracranial tumour (meningioma with obstructive h…
Mary Patricia Kruger, aged 69, died of bronchopneumonia complicating a massive subfrontal meningioma with obstructive hydrocephalus. Her death was preventable. During a November 2006 hospital admission for urinary tract …
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