74y · Female·Diabetic ketoacidosis
… refused transfer on three occasions, but experts found her decisional capacity was impaired by severe hyperglycaemia (BGL >15 mmol/L causes cognitive changes). No doctor personally assessed her to discuss risks or confi…
Unknown·Multiple injuries sustained in a motor vehicle accident. For Mohammad Shahidulla…
This is a road traffic accident involving a red Toyota Yaris driven by Anwar Jahid that collided head-on with a Toyota HiAce on John Gorton Drive, Whitlam, ACT on 16 October 2022. Three passengers—Mohammad Shahidullah, S…
29y · Male·Diabetic ketoacidosis
…r-prick glucose test or urine dipstick at the initial consultation would likely have identified severe hyperglycaemia and ketosis, prompting immediate hospital referral. The GP acknowledged in retrospect that these point…
64y · Female·head injury sustained in a single motor vehicle accident
… 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-mortem biochemical confirmat…
83y · Female·Diffuse Alveolar Damage in a woman with recent leg fracture and Atherosclerotic …
An 83-year-old woman with diabetes, cardiovascular disease, and mobility limitations fell from her bed while on a bedpan at an aged care facility, sustaining a compound ankle fracture. The registered nurse on duty had le…
16y · Male·Hypoxic/ischaemic encephalopathy in the context of diabetic ketoacidosis
…chlan was expected to self-manage his condition while acutely unwell despite cognitive impairment from hyperglycaemia. The coroner found the death was preventable through proper information sharing, staff training, and e…
84y · Female·Major cerebral infarct due to hypoglycaemia
Marie Goder, an 84-year-old with diabetes, developed severe hypoglycaemia following insulin administration at a nursing home on 1 November 2009, resulting in prolonged unconsciousness and bilateral cerebral infarcts. Aft…
29y · Male·cardiac arrhythmia
…likely precipitated by the combination of prone restraint-induced hypoxia, poorly controlled diabetes, hyperglycaemia, antipsychotic medications that prolong QT interval, obesity, and extreme stress. Better decision-maki…
29y · Male·Ketoacidosis as a consequence of diabetes mellitus (Type 1)
Steven Thelander, aged 29, died from ketoacidosis due to poorly controlled Type 1 diabetes while in residential disability support care at Multicap. He had cerebral palsy with severe intellectual impairment and epilepsy …
46y · Female·Dilated cardiomyopathy (acute complication with sudden cardiac arrhythmia)
…d cardiomyopathy with sudden arrhythmia. She presented to hospital multiple times in January 2015 with hyperglycaemia and respiratory symptoms but was discharged rapidly with minimal investigation or carer education. Key…
38y · Female·Unable to be determined
Kellie Anne Levitski disappeared on 31 March 2014 from her father's property near Bega, NSW. She had schizoaffective disorder requiring intensive mental health support, depot antipsychotic injections, and multiple medica…
55y · Male·cardiac arrest in the setting of methylamphetamine toxicity, with possible serot…
Angelo Gioscio, aged 55, died from cardiac arrest in the setting of methylamphetamine toxicity with possible serotonin syndrome, complicated by pre-existing cardiac and respiratory disease, whilst in police presence. He …
80y · Male·general inanition and pneumonia on a background of advanced vascular dementia, c…
Ian Ross Lauder, aged 80, died at an aged care facility from pneumonia and general inanition on a background of advanced vascular dementia, cerebrovascular disease, and a recently operated right hip fracture. He had suff…
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…
73y · Female·pneumonia and renal failure with hyperthermia
Beryl Jean Morgan, 73-year-old aged care resident, died from pneumonia and renal failure with hyperthermia after a brief hospital admission. She had been prescribed haloperidol for behavioural problems; while neuroleptic…
24y · Female·diabetic ketoacidosis in the setting of diabetes mellitus
Kylie Anne Lightfoot, a 24-year-old woman with type 1 diabetes, died from diabetic ketoacidosis. She presented to Dr S.'s practice on 4 May 2007 with abdominal pain, having not checked her blood sugar or taken insulin th…
66y · Male·Complications of chronic lithium therapy
Sydney Kennedy, a 66-year-old man with intellectual disability and bipolar affective disorder, died from complications of chronic lithium therapy. He had been on lithium for years with annual psychiatric review, but ther…
75y · Female·organ failure due to sepsis, likely from infected pressure sores, in the context…
Maria Carmel Niceforo, a 75-year-old woman with poorly controlled diabetes and ischaemic heart disease, died from septic shock secondary to extensive infected sacral pressure wounds. She received home care through KinCar…
17y · Male·Diabetic ketoacidosis
Caleb Pearson, a 17-year-old with undiagnosed Type 1 diabetes, presented with pharyngitis and was diagnosed and treated for a throat infection by his GP on 25 May 2015. Over the following two days he deteriorated with vo…
85y · Male·Heat stroke
An 85-year-old man with dementia, diabetes, and aortic stenosis died from heat stroke after spending 2 hours 18 minutes unmonitored in an unsheltered outdoor garden area at a residential aged care facility. The resident …
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