0y · Female·Perinatal asphyxia
…s rather than potentially at 1 minute); higher ventilation pressures could have been considered earlier; laryngeal mask airway should be considered after failed intubations; umbilical catheter securement technique requi…
20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…
…this did not occur for approximately 46 minutes. Staff attempted blind bougie instrumentation and bag-valve-mask ventilation through a displaced tube, causing bilateral tension pneumothoraces. Delays in emergency airway …
1y · Male·hypoxic brain damage due to laryngeal obstruction from foreign body (metal screw…
An 11-month-old boy died from hypoxic brain damage following aspiration of a 2cm metal screw that lodged in his larynx. The child was left briefly unsupervised at home when he ingested the screw and began choking. Parent…
56y · Male·Hypoxia and cardiac arrest with contributing conditions of Ischaemic Heart Disea…
…erative assessment, unaware of the defibrillator despite it being documented. Inappropriate anaesthesia (laryngeal mask with total intravenous propofol) was used for this high-risk patient. During surgery, the patient e…
26y · Male·acute cocaine and alcohol toxicity
AAB, a 26-year-old man with a history of substance abuse and mental health issues, died from acute cocaine and alcohol toxicity while in police custody. He presented to a hotel with agitated, paranoid behaviour and was d…
57y · Female·Complications of muscular dystrophy
A 57-year-old woman with longstanding muscular dystrophy and newly diagnosed cardiomyopathy died from complications of her underlying condition. She became acutely unwell overnight at her residential support facility wit…
18y · Female·Generalised tonic-clonic seizure and cardiac arrest arising from severe hyperten…
An 18-year-old pregnant woman presented in labour at 41 weeks and 2 days gestation. From 23 September onwards, she experienced intermittent headaches, epigastric pain, proteinuria and peripheral oedema. At 1755 hours on …
36y · Male·Gunshot wounds to the chest and abdomen
…d. While systemic issues were identified (police communication delays about warnings, missing resuscitation mask), these were not outcome-changing. Key clinical lessons: recognition of deteriorating mental health despite…
67y · Male·Complicated endotracheal tube insertion due to or as a consequence of recent clo…
…remature twin born at 31 weeks gestation weighing 1036g, died from complications of endotracheal tube re-insertion at 67 days of age. Following successful surgical ligation of a patent ductus arteriosus (PDA), Oliver de…
35y · Male·unascertained - multifactorial cardiorespiratory arrest
A 35-year-old male died in police custody following arrest for dangerous driving and property damage. He displayed acute psychotic behaviour with paranoia, aggression, and 'super-strength' during restraint. Post-mortem e…
39y · Male·Choking on a food bolus
Mark Capovilla, a 39-year-old man with severe intellectual disability, epilepsy, and dysphagia, died from choking on food at his day program. He had a documented choking risk but lacked a current mealtime support plan at…
54y · Male·acute myocardial infarction due to coronary artery atherosclerotic disease
Brett Furner, a 54-year-old man with significant coronary artery disease and recent myocardial infarction (February 2023), suffered an acute myocardial infarction and cardiac arrest while in police custody at Goulburn po…
25y · Male·traumatic basal subarachnoid haemorrhage due to vertebral artery dissection
Phillip Hughes, a 25-year-old professional cricketer, died from traumatic basal subarachnoid haemorrhage caused by vertebral artery dissection after being struck on the neck by a cricket ball during a Sheffield Shield ma…
28y · Female·3,4-methylenedioxy-N-methylamphetamine (MDMA) and ketamine toxicity
Trang Thi Thu Le, 28, died on her birthday from MDMA and ketamine toxicity after attending an electronic dance music event at John Cain Arena. She collapsed after consuming drugs purchased from an unknown source within t…
35y · Male·atherosclerotic heart disease with methylamphetamine effect in a man under physi…
A 35-year-old male with severe pre-existing ischaemic heart disease and recent cardiac arrest (April 2016) presented with increasingly erratic and paranoid behaviour after methylamphetamine use and alcohol consumption. H…
31y · Male·Status epilepsy secondary to cerebral cavernoma
Jesse Riley, a 31-year-old with undiagnosed cerebral cavernoma, experienced status epilepticus triggered by an unknown cause (possibly nicotine from recent vaping). While in post-ictal delirium, he was perceived as aggre…
31y · Female·cerebral anoxia following attempted intubation pre-surgery in a woman with torti…
Rachael Anne Rasmussen, a 31-year-old mother of three with severe neck deformities (torticollis, dysmorphia, short rigid neck), died on 17 June 2003 from cerebral anoxia following attempted intubation at Joondalup Health…
69y · Female·Respiratory obstruction by aspirated food (Brussels sprout, chicken and carrots)…
Helena Czekajlo, aged 69, died from respiratory obstruction by aspirated food (Brussels sprout) at a nursing home. She had dementia and schizophrenia with a documented obsession about food and tendency to eat hurriedly. …
39y · Male·Hypoxic brain injury due to respiratory obstruction following surgery for dental…
Richard Christopher Jankowski, a 39-year-old man, died from hypoxic brain injury due to respiratory obstruction following emergency surgery for a dental abscess with cellulitis. After initial treatment with antibiotics, …
18y · Female·Acute Alcohol Toxicity with Early Pneumonia and Aspiration
An 18-year-old female, a naive drinker, consumed approximately 19-21 standard drinks over a few hours at her birthday party, including vodka cruisers, a full-strength Midori drinking game, and Polmos (95% alcohol). She r…
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