36y · Male·Acute on Chronic Myocardial Infarction
Mark Anselo Ugle, a 36-year-old Aboriginal man with a significant history of cardiac problems, seizures, and non-compliance with medication, died in East Perth Lockup on 9 December 2000 from acute on…
67y · Male·hypothermia
Richard Thorn, a 67-year-old man with a history of alcoholism and back problems affecting mobility, was found deceased on his bedroom floor. Autopsy confirmed death from hypothermia (co…
44y · Male·Bilateral pneumonia in a man with Downs Syndrome
Brian Maher, a 44-year-old man with Down syndrome, died from bilateral pneumonia following rapid clinical deterioration. He presented to hospital on 2 December 2017 with dyspnoea and was admitted to the emergency departm…
59y · Male·ischaemic heart disease in the setting of chronic ethanol use
…at 7:38 am, by which time Robert was found in cardiac arrest and deceased. The autopsy confirmed ischaemic heart disease with chronic ethanol use as the cause. The 3-hour delay was attributed to staff shortages and decr…
68y · Male·Immersion (drowning), or alternatively injury sustained on rocks; cause of death…
Jan Zapotocky, a 68-year-old man, went fishing at Canal Rocks, Yallingup on 21 March 2014 and was washed into the ocean. His car was found in the car park five days later with fishing equipment inside. Expert opinion ind…
47y · Male·Acute opioid (Heroin) toxicity
Ali Kizildag, 47, died from acute opioid (heroin) toxicity while in custody at Dawn De Loas Correctional Centre on 11 September 2018. He was found unresponsive in his cell after failing to return from a medical appointme…
Three separate cases: (1) Ronald Grundy - advanced atherosclerotic coronary vasc…
…congestive cardiac failure and atherosclerotic cardiovascular disease after a lifetime of complex cardiac problems; he received appropriate specialist care and his death occurred in accordance with his goals of care plan…
76y · Male·exsanguination secondary to pulmonary aortic fistula and thoracic aorta aneurysm…
…arily detained under mental health legislation and treated for depression while managing multiple cardiac problems including anaemia and poor oral intake. He died suddenly from massive haemorrhage secondary to rupture of…
56y · Male·aspiration pneumonitis secondary to airways obstruction from squamous cell carci…
… of investigations requires documented clinical justification; multidisciplinary assessment of swallowing problems improves diagnostic yield. Earlier endoscopy (September/October 2019) would have identified malignancy so…
83y · Female·Complications following fracture and surgical repair of the left hip in an elder…
Nola Inez Daniel, 83, died from complications following a hip fracture and subsequent surgery at Bunbury Regional Hospital on 7 January 2010. She sustained a fractured left neck of femur during a fall at Regis Forrest Ga…
51y · Female·Complications of anorexia nervosa
… severe anorexia nervosa, BMI 12.1, was admitted to hospital acutely unwell with hypothermia, bradycardia, heart block, and extreme malnutrition. She was discharged after only 2 days with minimal medical follow-up and n…
74y · Male·Ischaemic heart disease in association with coronary artery atherosclerosis
Mr Harris, a respected Aboriginal elder aged approximately 74 years, died of ischaemic heart disease with coronary artery atherosclerosis while travelling bush alone on 2 February 2010. He bogged his…
48y · Male·myocardial infarction due to ischaemic heart disease due to hypertension
A 48-year-old man died from myocardial infarction due to ischaemic heart disease and hypertension shortly after undergoing urology surgery. Critical failures in clinical communica…
Female·Vlasta Wylucki: ischaemic heart disease due to coronary atherosclerosis (previou…
…d police watchhouses but supervisory failures raised serious concerns. Ms Wylucki (50) died from ischaemic heart disease after inadequate cell checks failed to detect her vomiting overnight; had she been checked properl…
33y · Male·Longstanding atheromatous coronary artery disease with severe stenosis and cardi…
A 33-year-old Aboriginal man died in custody from longstanding atheromatous coronary artery disease with cardiac hypertrophy. On presentation to the prison clinic with non-specific symptoms (headache, throat pain, arm an…
30y · Male·Malignant ventricular arrhythmia without myocardial infarction, precipitated by …
…uting factors included positional asphyxia, exertion, taser use (deployed three times), and his underlying heart disease. Critical failures included: no ambulance called early despite known mental health crisis; inadequ…
Multiple causes across 22 deaths: ligature compression of the neck (17 hangings)…
This coronial inquiry examined 22 deaths of Aboriginal people in the Kimberley region of Western Australia between 2000 and 2007. Seventeen were self-harm deaths, with four additional accidental deaths and one homicide. …
72y · Female·Peritonitis due to perforated diverticulum in transverse colon
Maria Donatelli, a 72-year-old woman with cardiac and renal disease, presented to Peel Health Campus with abdominal pain and vomiting. She was initially managed conservatively with a provisional diagnosis of pancreatitis…
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