88y · Male·Sepsis of unknown aetiology in a man with ischaemic cardiomyopathy and other med…
…y. Despite antibiotic therapy and supportive care, he deteriorated with delirium, acute kidney injury, and liver dysfunction. He was deemed unsuitable for CPR or intubation. He died suddenly on 9 July 2021. The coroner …
52y · Male·Drowning in Falcon Bay
…hony Duffy, a 52-year-old man with multiple serious chronic conditions including osteoarthritis, diabetes, liver dysfunction from alcohol abuse, and peripheral vascular disease requiring bypass surgery, disappeared into…
51y · Female·community acquired pneumonia
…ation. During treatment, an Acomed infusion pump failed silently, temporarily compromising noradrenaline delivery when her blood pressure was critically low (60 mmHg systolic). Despite manual administration resumption a…
64y · Male·Heart failure secondary to alcohol related liver disease, coronary obstructive p…
Emanuel Mavridis, aged 64, died of heart failure secondary to alcohol-related liver disease, COPD, and ischaemic/alcoholic cardiomyopathy. He presented to Royal Adelaide Hospital hypotensive…
44y · Male·cardiogenic shock, on a background of severe tricuspid valve regurgitation, seve…
…dence indicated his condition was inoperable due to severe pulmonary hypertension and right ventricular dysfunction, with surgery contraindicated by recent upper GI bleeding requiring anticoagulation. Both gastroenterol…
39y · Female·multiorgan failure and probable sepsis
…ade, treated surgically by drainage. Despite initial haemodynamic improvement, she developed multiorgan dysfunction including acute kidney injury, liver failure, and pneumonia with ongoing seizures. After discussion wit…
17y · Unknown·hypoxic brain damage from out of hospital cardiac arrest
…st, and died from hypoxic brain damage. Contributing factors included his underlying short bowel syndrome, liver/pancreatic/splenic dysfunction from long-term TPN, and possible aspiration or sepsis. Key clinical lessons…
54y · Male·Unascertained
…lood cultures, imaging, and microbiology. He deteriorated with coagulopathy, DIC, acute kidney injury, and liver dysfunction, dying four days later. The coroner could not determine cause of death due to uncertainty rega…
29y · Female·multi-lobe community acquired pneumonia and respiratory failure
…n 5 January 2015 and admitted with severe malnutrition (BMI 9.36), bilateral pneumonia, and multi-organ dysfunction. The treating team, led by psychiatrist Dr T. and physician Dr E., managed a complex case balancing her…
80y · Male·metastatic hepatocellular carcinoma
…end-of-life care plan. His clinical deterioration was consistent with terminal carcinoma, with progressive liver failure, electrolyte derangements, and decreased consciousness. The coroner found no evidence of deficient…
62y · Male·hepatic encephalopathy due to acute renal failure
…C, diabetes, hypertension, and kidney disease documented years before his death. During incarceration, his liver disease progressively worsened. He was appropriately transferred to hospital in December 2016 when prison …
52y · Female·ischaemic and hypertensive heart disease
…iepin 225mg daily for depression management. Following gallbladder surgery in April 2009, she had deranged liver function tests (elevated GGT and ALP). The coroner examined whether dothiepin should have been reduced giv…
72y · Male·Haemopericardium due to anti-coagulation treatment for pulmonary thromboemboliti…
Jeffrey Brown, a 72-year-old with recent cardiac surgery (CABG), died from haemopericardium due to anticoagulation treatment for pulmonary thromboembolism. Post-mortem examination revealed fibrinous pericarditis (a known…
59y · Male·multiorgan failure complicating paracetamol toxicity
… overdose. Police responded promptly and he was transferred to Dandenong Hospital where he developed acute liver failure and multi-organ failure despite maximal intensive care and N-acetylcysteine. Transfer to Austin Ho…
63y · Male·metastatic small cell lung carcinoma with ischaemic heart disease as a significa…
A 63-year-old man serving a custodial sentence died of metastatic small cell lung carcinoma with contributing ischaemic heart disease. One month before death, he presented with constitutional symptoms and was diagnosed w…
2y · Male·multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndro…
A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poo…
10y · Female·Multi-organ failure secondary to overwhelming herpes simplex virus (HSV) infecti…
…ntly seen by two other doctors who also did not consider HSV. By Friday (day 5), blood tests showed severe liver dysfunction and dehydration but were not acted upon appropriately. Critical failures included: not includi…
58y · Female·pneumonia, likely aspiration pneumonia
Mary Marguerite Dickinson, aged 58, died of pneumonia on 20 January 2018 at the Roy Fagan Centre after admission with a complex scapula fracture and severe cognitive decline from alcoholic dementia. The coroner found her…
55y · Male·gastrointestinal haemorrhage due to oesophageal varices due to hepatocellular ca…
Robert McIntosh, a 55-year-old prisoner with undiagnosed cirrhosis of the liver, hepatitis C, and hepatocellular carcinoma, died from gastrointestinal haemorrhage and oesophageal varices…
68y · Male·community-acquired pneumonia in a setting of advanced centriacinar emphysema, al…
…ar-old man died of community-acquired pneumonia complicated by asplenia (absent splenic function), chronic liver disease from alcohol misuse, and severe malnutrition. He presented with syncopal episodes, cachexia, and m…
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