79y · Female·subdural haematoma following mechanical fall with head strike
A 79-year-old woman with multiple comorbidities including diabetes, peripheral neuropathy, and previous partial foot amputation fell backwards in a hospital toilet on 23 November 2018, striking …
58y · Male·Atherosclerotic cardiovascular disease
…2 diabetes since 1985, hypertension, coronary artery disease (with prior bypass surgery), and significant diabetic complications including amputations. The coroner found he received appropriate medical care at the correc…
75y · Male·Hypovolemic shock caused by multiple injuries to the chest, abdomen and pelvis s…
…ed by Mr Pettigrew's inattentiveness and failure to give way. Although medically cleared to drive despite diabetic neuropathy, his daughter had noted lifelong concerns about his driving—distraction and lane drift. The co…
29y · Female·acute myocardial infarction due to stenotic coronary vessel (left anterior desce…
Rebecca Richardson, a 29-year-old with type 1 diabetes and coronary artery disease, died of acute myocardial infarction on 7-9 May 2019. She presented to NWRH ED on 6 May with abdominal pain and vomiting, initially attri…
54y · Female·Respiratory failure secondary to pneumonia, due to multiple sclerosis
A 54-year-old woman with multiple sclerosis residing in specialist disability accommodation died of respiratory failure secondary to pneumonia. She presented with breathing difficulty and vomiting on 10 January 2024, was…
54y · Male·Respiratory failure secondary to prolonged ventilation for management of sepsis …
…onal Centre when his condition deteriorated. Critical clinical lessons include: (1) patients with chronic diabetic ulcers refusing treatment require enhanced vigilance and structured monitoring; (2) wound care management…
78y · Male·COVID-19 pneumonitis on a background of ANCA nephropathy, hypertension, and diab…
Denis Ives, a 78-year-old man with type 1 diabetes, chronic kidney disease stage 4, ANCA nephropathy and hypertension, died of COVID-19 pneumonitis while in custody at Long Bay Correctional Centre. He tested positive for…
61y · Male·lung carcinoma
Kelvin Gardoll, a 61-year-old man, died in custody from lung carcinoma on 4 August 2014 at Long Bay Correctional Complex Hospital. He had presented with a skin lesion that was excised in 2010 (histologically confirmed as…
75y · Male·Gunshot wound to the head
Luciano T, a 75-year-old man with complex medical and psychiatric history including chronic pain, depression, and delusional jealousy syndrome, shot his wife in the face and then fatally shot himself. He had been under p…
68y · Female·Massive blood loss due to disconnection of haemodialysis machine
Judith Heath, age 68, died from acute blood loss on 7 September 2006 at The Alfred Hospital during routine haemodialysis for end-stage renal failure. The Luer-Lok connection between her arteriovenous catheter and the hae…
73y · Male·multisystem organ failure in the context of trauma and limb fracture
A 73-year-old Indigenous man with multiple comorbidities (diabetes, hypertension, obesity, sleep apnoea, ischaemic heart disease) sustained a right ankle fracture following collision with a motor vehicle while riding a m…
24y · Female·hypoxic brain injury following unexplained cardiorespiratory arrest
A 24-year-old female with brittle Type 1 diabetes and multiple comorbidities presented to Joondalup ED with a rapidly spreading blistering rash on 3 September 2009. Dr C. appropriately identified a potentially serious de…
46y · Male·Aspiration pneumonia in an obese man with a history of diabetes mellitus, obstru…
Samuel Edward Ashby, a 46-year-old prisoner with treatment-resistant schizophrenia, died from aspiration pneumonia complicated by clozapine effect. Key clinical lessons: (1) smoking cessation dramatically increases cloza…
53y · Male·Metastatic pancreatic carcinoma
Michael Sanderson, a 53-year-old Gamilaroi man, died from metastatic pancreatic cancer while in custody. Critical clinical lessons emerge: (1) failure to review pathology results within required 14-day timeframe delayed …
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