81y · Female·left haemothorax and mediastinal haemorrhage from the insertion site of the perm…
An 81-year-old woman died from haemothorax and mediastinal haemorrhage following pacemaker insertion for sick sinus syndrome. Multiple venous punctures during the procedure caused vascular injury…
62y · Male·fatal cardiac arrhythmia secondary to end-stage ischaemic cardiomyopathy
…diomyopathy died from a fatal cardiac arrhythmia in hospital. He had extensive cardiac history including pacemaker insertion, coronary stents, and bypass grafting. Throughout his 10-year imprisonment, he received numero…
69y · Male·Metastatic non-small cell lung cancer on a background of dilated cardiomyopathy,…
…in September 2015 and deemed untreatable given his comorbidities; he received palliative care. Following pacemaker infection in November 2015, cancer metastasized to the brain causing seizures. A comfort-care-only resus…
83y · Female·Pulmonary thromboembolism due to aortic stenosis (recent transcatheter aortic va…
…(TAVI). Clinical lessons centre on communication failures: an electrophysiologist's ambiguous note about pacemaker indication was misinterpreted by junior staff, and two concerning ECGs taken on discharge day were not e…
78y · Male·cardiomegaly with left ventricular hypertrophy and atherosclerotic cardiovascula…
…ease. He had significant cardiac history including prior myocardial infarction, cardiac arrest requiring pacemaker insertion, and severely reduced ejection fraction (20-25%). The coroner found that medical management du…
6y · Male·Acute on chronic respiratory failure in the setting of hypotonic quadriplegic ce…
…Hyatt, a 6-year-old with severe cerebral palsy, chronic lung disease, and cardiac arrhythmia requiring a pacemaker, died from acute on chronic respiratory failure following a respiratory infection. He was admitted to Ro…
83y · Female·Gunshot wound to the head
…to the head on 3 November 2016. She had extensive cardiac history including multiple valve replacements, pacemaker insertion, and congestive heart failure diagnosed in 2016. Two hospital admissions in October 2016 for h…
81y · Male·valvular heart disease with cardiac amyloidosis
… 81-year-old prisoner with extensive cardiac history including aortic stenosis, sick sinus syndrome with pacemaker, and recent TAVI procedure, collapsed and died in prison infirmary on 20 September 2019. Autopsy confirm…
60y · Male·haemopericardium due to rupture of right ventricle complicating removal of cardi…
Richard Allen, a 60-year-old man with a permanent pacemaker for sick sinus syndrome, died from haemopericardium due to rupture of the right ventricle during pacemak…
86y · Male·End-stage congestive cardiac failure on a background of dilated cardiomyopathy
Mark Lewis, aged 86, died from end-stage congestive cardiac failure in custody at Long Bay Hospital Aged Care Unit. He had multiple chronic conditions (dilated cardiomyopathy, chronic kidney disease, diabetes, ischemic h…
38y · Female·Combined effects of ischaemic and valvular heart disease with methamphetamine us…
…e had pre-existing severe ischaemic and valvular heart disease requiring multiple valve replacements and pacemakers, likely secondary to her substance use. Toxicology revealed fatal levels of methamphetamine and cannabi…
57y · Male·carcinoma of the right lung
Alfred Firth Thorpe, a 57-year-old man imprisoned for manslaughter, died of carcinoma of the right lung whilst in custody. He had declined radiotherapy for throat cancer in 1999, which may have prevented recurrence. Lung…
83y · Male·cholangiocarcinoma on a background of advanced dementia and ischaemic valvular a…
Joseph McKenna, 83 years old, died of cholangiocarcinoma with advanced dementia and cardiac disease at an aged care facility where he was detained under a guardianship order. He was appropriately managed with palliative …
83y · Male·Congestive cardiac failure due to ischaemic and valvular heart disease, with her…
Frank Valentine, an 83-year-old man, died from congestive cardiac failure due to ischaemic and valvular heart disease, with hereditary haemorrhagic telangiectasia (HHT) and anaemia as contributory conditions. He was serv…
64y · Female·Haemorrhage into atheromatous plaque, due to coronary atherosclerosis
…morrhage into atheromatous plaque. She suffered an acute cardiac event on 5 May 2008 requiring emergency pacemaker insertion. After three weeks in ICU with mechanical ventilation, she was transferred to a medical ward w…
73y · Male·Acute on chronic renal failure and multi-factorial encephalopathy in a man with …
A 73-year-old man with significant comorbidities (cirrhosis, dilated cardiomyopathy, chronic kidney disease) died in prison from acute-on-chronic renal failure, hepatic encephalopathy, and multiorgan failure. He was init…
0y · Female·Pneumonia in an infant with surgically repaired congenital heart disease, premat…
A 9.5-month-old girl with complex medical history (prematurity at 29 weeks, congenital heart disease status post multiple repairs, necrotising enterocolitis with ileostomy, failure to thrive) died from acute pneumonia ca…
74y · Male·Intra-abdominal haemorrhage complicating elective umbilical hernia repair
A 74-year-old man with significant cardiac history (atrial fibrillation, dilated cardiomyopathy, pacemaker) underwent elective umbilical hernia repair. Intraoperatively, unexpected ascites was discovered and par…
57y · Male·Head injury from fall; with coronary atherosclerosis and complete heart block wi…
A 57-year-old man with bipolar disorder died from head injury following a fall at Toowong Private Hospital. Critical failures in falls risk management were identified: no formal falls risk assessment was completed on adm…
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