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…
73y · Female·end stage renal failure
Patricia Andrew, a 73-year-old woman with Down syndrome, end-stage renal failure, type 2 diabetes, and intellectual disability, was resident in a Department of Human Services community unit. She deteriorated over several…
64y · Female·head injury sustained in a single motor vehicle accident
…n levels were dropping. The coroner could not definitively establish whether the accident was caused by a diabetic emergency (hyperglycaemia suggested by pump alarm and comments) or inattention/distraction, as post-morte…
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 her head on a sink and flo…
20y · Male·closed head injury
…ng to turn right at a traffic junction in poor visibility. The driver was monocular (one eye only) due to diabetic complications and failed to detect the scooter despite its lights being illuminated. Critical failures in…
51y · Male·complications of myocardial infarction in association with ischaemic heart disea…
…o chest and chest tightness; an ECG was normal and he was not admitted despite atypical presentation in a diabetic patient. On 1 February, he presented with worsening chest pain and low oxygen saturation (89%), was appro…
62y · Male·fatal cardiac arrhythmia secondary to end-stage ischaemic cardiomyopathy
A 62-year-old prisoner with severe ischaemic heart disease, diabetes, and cardiomyopathy died from a fatal cardiac arrhythmia in hospital. He had extensive cardiac history including pacemaker insertion, coronary stents, …
44y · Male·Unascertained; presumed exposure
Roly Nixon, a 44-year-old man with significant medical comorbidities including rheumatic heart disease, diabetes, organic psychosis and seizure disorder, disappeared from Fitzroy Crossing, Western Australia on 28 January…
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…
61y · Male·end stage renal failure, in the context of type 2 diabetes mellitus and chronic …
Robert Curtis, a 61-year-old Aboriginal man with end-stage renal disease, end-stage liver disease, and poorly controlled diabetes, was imprisoned for driving while disqualified on 4 February 2019. He fell in the prison s…
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…
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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