40y · Male·ischaemic heart disease due to left ventricular hypertrophy and coronary artery …
A 40-year-old Aboriginal man with longstanding rheumatic heart disease, left ventricular hypertrophy, and coronary artery atherosclerosis died from acute myocardial infa…
86y · Male·End-stage congestive cardiac failure on a background of dilated cardiomyopathy
…it. He had multiple chronic conditions (dilated cardiomyopathy, chronic kidney disease, diabetes, ischemic heart disease) and had signed advance care directives refusing cardiopulmonary resuscitation. He was appropriate…
57y · Male·Aspiration of gastric content (due to choking on food)
Christopher Barca, a 57-year-old man with Down syndrome and intellectual disability living in a Department of Human Services group home, died from aspiration of gastric content. He had oropharyngeal dysphagia, epilepsy, …
Three separate cases: (1) Ronald Grundy - advanced atherosclerotic coronary vasc…
Three men died in custody in Tasmania between 2016 and 2017. Ronald Grundy (80) died of advanced atherosclerotic coronary vascular disease while hospitalised with pneumonia and gastroenteritis; his treatment was adequate…
36y · Male·infective endocarditis
John Clive Anderson, a 36-year-old prisoner, died from infective endocarditis despite being evaluated 25 times by prison medical officer Dr P. between February and May 2009. Dr P. documented possible infective endocardit…
57y · Male·Head injury from fall; with coronary atherosclerosis and complete heart block wi…
…Hospital. Critical failures in falls risk management were identified: no formal falls risk assessment was completed on admission despite prior fall history, despite clear clinical indicators of increased fall risk (unste…
89y · Male·Complications in association with a gastrointestinal illness in an elderly man w…
…g restraints for elderly, frail, terminally ill prisoners without risk assessment. No risk assessment was completed before transfer to hospital. Restraints remained for 7 days until his death, violating dignity and polic…
83y · Female·Pulmonary thromboembolism due to aortic stenosis (recent transcatheter aortic va…
An 83-year-old woman with severe aortic stenosis, atrial fibrillation, and heart failure died from pulmonary embolism one day after discharge following transcatheter aortic valve replacem…
86y · Female·Cardiogenic shock
Adelaide Wilson, 86 years old, presented to an urgent care centre with two days of chest pain and vomiting. A point-of-care troponin test (i-STAT) returned 0.4 ng/L, interpreted as normal, and she was discharged with gas…
79y · Male·Respiratory failure due to haemothorax and hospital-acquired pneumonia due to mu…
A 79-year-old man with extensive comorbidities died following multiple falls in residential aged care. He was identified as high falls risk on admission but experienced inadequate falls prevention after a second fall on …
68y · Female·Coronary heart disease
…nd died despite resuscitation. Clinical lessons: inadequate length of stay for diagnostic clarity in acute heart failure; failure to act on abnormal vital signs and Q-ADDS scores; poor discharge planning with no pharmac…
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