15y · Male·bronchopneumonia secondary to chronic chest dysmorphology caused by congenital b…
Lee Shaun Wurramarrba was a 15-year-old severely disabled boy with cerebral palsy, global developmental delay, kyphoscoliosis, epilepsy, and chronic chest anatomical distortion who died from bronchopneumonia. He was in s…
87y · Female·acute intracranial haemorrhage
An 87-year-old woman with dementia, hypertension, and DVT died from acute intracranial haemorrhage while an inpatient at a general hospital under a Mental Health Act detention order. She was on warfarin for DVT managemen…
79y · Male·Complications associated with metastatic colorectal carcinoma and diabetes melli…
Kenneth Johnstone, a 79-year-old prisoner with extensive comorbidities including metastatic colorectal cancer, diabetes, stage 4 chronic kidney disease, and osteomyelitis, died from cancer complications. He was appropria…
89y · Female·Aspiration pneumonia and malnutrition, with contributing factors of dysphagia an…
Janet Cumming, aged 89, died from aspiration pneumonia and malnutrition due to dysphagia and cerebral palsy. She had lived in supported disability accommodation for over 20 years and required 24-hour care. In her final w…
92y · Female·Complications of congestive cardiac failure (palliated) in an elderly woman with…
This case involves an elderly woman with congestive cardiac failure, intellectual disability, and multiple comorbidities who died in a Department of Human Services residential care facility. In late September 2012, she d…
78y · Female·advanced dementia (end stage)
Mrs Lorraine Ashton, aged 78, died of advanced dementia (end stage) at Repatriation General Hospital on 23 September 2017. She had Primary Progressive Aphasia diagnosed in 2014 following non-Hodgkin's lymphoma treatment.…
85y · Male·general inanition on a background of end stage dementia
An 85-year-old man with advanced mixed fronto-temporal and Lewy body dementia died from general inanition (wasting) following progressive decline over several years. He was hospitalised in July 2017 after becoming unmana…
57y · Male·Complications of Down syndrome
Brian Leslie Aldridge, a 57-year-old man with Down syndrome, cerebral palsy, intellectual disability and Alzheimer's dementia, died of natural causes in specialist disability accommodation. He experienced declining healt…
72y · Male·Complications of a gastroduodenal perforation (palliated) in the setting of mult…
William Anthony Daniel, a 72-year-old SDA resident with intellectual impairment and multiple comorbidities, presented to Box Hill Hospital on 7 November 2024 with postural hypotension, nausea, vomiting and abdominal pain…
56y · Male·Hypoxic ischaemic encephalopathy following cardiac arrest
Anthony Gaylard, a 56-year-old man with severe intellectual disability living in residential care, suffered a cardiac arrest on 14 September 2012 (note: document states 2007 in one place, 2012 elsewhere; finding date is …
82y · Male·Acute myocardial infarction caused by ischaemic heart disease
Francis Sawle, an 82-year-old man in custody, died of acute myocardial infarction due to ischaemic heart disease while an inpatient at Prince of Wales Hospital. He had significant comorbidities including severe triple ve…
80y · Male·complications of necrotising pancreatitis secondary to pancreatic biopsy (EUS)
John Twycross, an 80-year-old man with a history of hypertension, asthma, glaucoma and prior cholecystectomy, presented with acute pancreatitis in April 2011 after imaging revealed a suspe…
58y · Female·Acute subdural haemorrhage due to blunt force trauma to the head
Brenda Elizabeth King, 58, died from acute subdural haemorrhage following blunt head trauma. She had chronic alcoholism and documented history of falls when intoxicated. The coroner could not definitively determine wheth…
76y · Male·Sepsis, with osteomyelitis and infective endocarditis
Alex Mills, a 76-year-old sentenced prisoner with complex medical history including atrial fibrillation, valvular heart disease, and rheumatoid arthritis, died from sepsis caused by osteomyelitis and infective endocardit…
1y · Female·aspiration of gastric contents due to recent gastroenteritis and vomiting leadin…
Bridgett Currah was a 19-month-old girl with complex medical needs including cyanotic congenital heart disease, gastro-oesophageal reflux, and feeding difficulties. She presented to Mildura Base Hospital on 21 May 2013 w…
82y · Male·Self-inflicted partial contact shotgun wound of the head
An 82-year-old man with recently diagnosed myeloma died by self-inflicted shotgun wound. He had undergone intensive chemotherapy causing significant deterioration in physical health, mental state, and independence. Six w…
77y · Female·hypothermia from environmental cold exposure with contributing factors of advanc…
Mrs Janet Mackozdi, aged 77, died from hypothermia in an uninsulated shipping container at Mount Lloyd, Tasmania, on 23-24 July 2010. She had advanced Alzheimer's dementia and required 24-hour care. The coroner found her…
0y · Male·Trisomy 21 with complex cardiac anomalies complicated by pulmonary hypertension,…
Baby G, born with Trisomy 21 (Down Syndrome) and complex cardiac anomalies, died at Royal Darwin Hospital on 18 March 2023 aged 6 months. The coroner found that non-invasive prenatal testing (NIPT) should have been offer…
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