75y · Female·cardiac arrest in the context of aortic stenosis (moderate to severe), coronary …
…red cardiac arrest approximately 15 hours post-operatively. Investigation revealed potential delays in defibrillation and inadequate familiarity of nursing staff with resuscitation equipment. Key clinical lessons: pre-op…
73y · Male·Coronary atherosclerosis with hypertension, diabetes mellitus, emphysema and per…
John William Chardon, a 73-year-old prisoner, died from coronary atherosclerosis with severe calcified atheroma causing >70% stenosis of coronary arteries. He presented with dizziness on 21 October 2020, which initially …
49y · Male·Cardiac arrhythmia in a man with methylamphetamine effect and cardiomegaly
…022 in Western Australia. He was being pursued by police following serious criminal allegations including attempted shooting and drug trafficking. After a brief police intercept that was appropriately terminated when of…
18y · Male·left haemopneumothorax due to traumatic rupture of the lower lobe of the left lu…
An 18-year-old male riding a motorcycle died when the vehicle crashed into a culvert while being pursued by police. The deceased was riding whilst disqualified from holding a licence and fled from police at moderate spee…
50y · Male·bronchitis (pandemic influenza A/H1N1 2009) in a man with chronic obstructive pu…
…urly vital sign monitoring given clozapine's potential for serious adverse effects. However, when a nurse attempted vital sign checks at 1.00am on 31 August, the deceased refused cooperation. Hourly visual checks and au…
25y · Female·mixed drug toxicity
…n October 2016. She had a longstanding history of serious mental illness with multiple documented suicide attempts and police welfare checks in the months preceding her death. After calling a counsellor from Rural Alive…
36y · Male·hanging
… failures: (1) Duty Supervisor Ken Cluse directed that Mr Turner not be cut down and resuscitation not be attempted, despite unclear signs of death and uncertain duration of hanging. The coroner found this decision inap…
14y · Male·severe heatstroke complicating a recent viral illness with focal myocarditis
A 14-year-old boy from Scotland died of severe heatstroke with myocarditis while hiking in extreme heat (40°C+) at Cape Range National Park. He had recently recovered from a viral illness. His father made navigation erro…
38y · Female·Drowning/Immersion due to coronary artery atheroma
Leila Michelle Trott, a 38-year-old experienced skipper and dive instructor, drowned after swimming approximately 400 metres to retrieve a drifted tender vessel off Green Island, Cairns. Unbeknownst to her, she had sever…
23y · Male·hypoxic brain injury and bronchopneumonia complicating ligature compression of t…
Jordan Robert Anderson, 23, died by suicide in Hakea Prison through ligature compression of the neck. Critical delays occurred when he was discovered unresponsive: 3 minutes 40 seconds elapsed before his cell door was un…
54y · Male·quetiapine toxicity in a man with ischaemic heart disease
… experienced a recent relationship breakdown and presented to Grampians Health (GH) with multiple suicide attempts within 72 hours. The Coroner found several key deficiencies in his mental health management: the initial…
29y · Male·cardiac arrhythmia
…g staff failed to monitor David's breathing when he complained of difficulty breathing; and resuscitation attempts were poorly coordinated and ineffective. The coroner concluded David died from cardiac arrhythmia, likel…
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