51y · Male·COVID-19 pneumonia
…arlier escalation would have changed the outcome, given his age, comorbidities (asthma, thalassaemia, hyperthyroidism) and COVID-19's severity. The coroner acknowledged the unprecedented pandemic pressures on health ser…
53y · Male·Pneumonia in a man with Down syndrome and dementia; epilepsy
Raymond Giles, a 53-year-old man with Down syndrome, dementia, epilepsy and recurrent chest infections, died of pneumonia while in residential care. On the morning of his death, staff noted a fever treated with paracetam…
59y · Female·complications of sepsis due to cellulitis in a woman with multiple medical comor…
Suzanne McIllree, 59 years old with significant intellectual disability and primary lymphedema, died from sepsis secondary to cellulitis. She was admitted to hospital on 6 August 2015 after carers noted fever, lethargy, …
72y · Male·Coronary artery atherosclerosis
Brian Roy Gallagher, a 72-year-old man with cerebral palsy and intellectual disability living in disability support accommodation, died from coronary artery atherosclerosis. He was noted to be unwell on the day of death …
63y · Female·Aspiration pneumonia in a woman with seizure disorder, Down syndrome, dementia a…
Sharon Harris, 63, died from aspiration pneumonia complicated by seizure disorder, Down syndrome, dementia, and normal pressure hydrocephalus. She was in specialist disability accommodation in Colac. In the months before…
82y · Male·atherosclerotic and hypertensive cardiovascular disease
Joseph Richard Oakley, aged 82, died from atherosclerotic and hypertensive cardiovascular disease at the Roy Fagan Centre, a psychiatric hospital for older persons. He had advanced Parkinson's disease, dementia, diabetes…
72y · Female·Bronchopneumonia
Diane Young, a 72-year-old psychiatric resident with multiple comorbidities including asthma, aortic stenosis, and intellectual disability, died of bronchopneumonia with contributing ischaemic heart disease. She was seen…
52y · Female·Renal Failure Complicating Urosepsis in a Woman with Down Syndrome (Palliated)
Lee Isabell Mills, a 52-year-old woman with Down syndrome, chronic renal failure, and requiring permanent catheterisation, developed urosepsis following a urinary tract infection. She presented with back pain, fever, and…
68y · Female·chronic obstructive pulmonary disease
Ms Sniecikowska, a 68-year-old Polish-speaking woman with severe COPD, chronic alcoholism, cognitive impairment, and significant social isolation, was admitted to hospital for acute COPD exacerbation on 29 August 2016. D…
Unknown·Diane Michel: sharp force injuries to neck and wrists. John McCain: projectile i…
A married couple, both terminally ill with COPD and other serious conditions, died together at home in December 2016. Diane Michel (74) died from sharp force injuries to her neck and wrists; John McCain (76) died from se…
71y · Male·end-stage cardiac failure on a background of ischaemic heart disease with dilate…
Keith Freeman, aged 71, died in custody from end-stage cardiac failure with ischaemic heart disease and dilated cardiomyopathy. He had complex cardiac history including previous CABG, aortic valve replacement, and implan…
74y · Female·Cardiac arrest due to pulmonary embolism secondary to deep venous thrombosis
A 74-year-old woman presented to ED with left leg swelling and calf pain. She was triaged as category 4 and seen by a doctor after a 4-hour 24-minute delay due to staff shortages and access block. A D-Dimer test showed e…
57y · Male·Hanging
A 57-year-old male inmate died by hanging at Long Bay Correctional Centre in January 2018. Although he had been psychiatrically assessed as experiencing major depression with psychotic features and was recommended by a p…
74y · Female·Infective exacerbation of chronic obstructive airways disease in the setting of …
Caroline McCormack, 74, died from infective exacerbation of chronic obstructive airways disease following a medication administration error where pregabalin was erroneously included in her Webster-pak despite being cease…
68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…
Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mi…
73y · Male·Acute intracranial haemorrhage, due to or as a consequence of coagulopathy, due …
Mr Stimpson, a 73-year-old man, died from massive intracerebral haemorrhage secondary to coagulopathy caused by inadvertent double administration of anticoagulants (Clexane and Xarelto). He developed bilateral pulmonary …
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