51y · Male·Acute myocardial infarction due to coronary atherosclerosis
… disease died in custody from acute myocardial infarction. He presented with gastrointestinal bleeding, pancytopenia, and cardiac decompensation requiring multiple resuscitations over four days. The coroner found medical…
80y · Female·Complications of chronic lymphocytic lymphoma in the setting of multiple medical…
Joyce Drummond, an 80-year-old woman with chronic lymphocytic lymphoma, pancytopenia, and intellectual disability, died from complications of her lymphoma in a palliative care setting. She…
55y · Male·Pneumonia, bone marrow failure and metastatic carcinoma of unknown origin
…ed with ongoing abdominal pain. He deteriorated with respiratory failure from pneumonia, complicated by pancytopenia. Bone marrow biopsy revealed metastatic adenocarcinoma of unknown primary with bone marrow failure. He …
69y · Male·Waldenstrom's Macroglobulinemia, a type of non-Hodgkin lymphoma
Colin Hay, a 69-year-old man serving a custodial sentence, died from Waldenstrom's Macroglobulinemia (a non-Hodgkin lymphoma) on 21 October 2016 in the Secure Unit Annex of Prince of Wales Hospital. He was diagnosed in J…
76y · Male·Intracranial Haemorrhage Secondary to Blunt Head Trauma (Fall) in the Setting of…
…with newly diagnosed chronic myeloid leukaemia in blast crisis was admitted to hospital with sepsis and pancytopenia from chemotherapy. He suffered multiple falls while confused from sepsis, sustaining a subdural haemorr…
59y · Female·Multiorgan failure and polymicrobial sepsis secondary to severe bone marrow fail…
A 59-year-old woman with renal transplant died from multiorgan failure and sepsis secondary to severe bone marrow failure caused by azathioprine toxicity. She had an undiagnosed genetic polymorphism (TPMT *3A/*3A homozyg…
92y · Female·heart failure secondary to aortic stenosis, anaemia, atrial fibrillation and isc…
A 92-year-old woman with multiple comorbidities (aortic stenosis, anaemia, atrial fibrillation, ischaemic heart disease) died of heart failure four days after admission to aged care. She had been hospitalised for three m…
75y · Male·bronchopneumonia
Barry Ronald Tate, 75, died of bronchopneumonia following a fall at a palliative care ward. He sustained an unwitnessed fall on 26 September 2019 while attempting to shave himself without assistance, despite being advise…
76y · Female·left lower lobe pneumonia complicating metapneumovirus infection
Maria Astachnowicz, aged 76, died from left lower lobe pneumonia complicating metapneumovirus infection at Lyell McEwin Hospital. She had extensive psychiatric history (schizoaffective disorder/bipolar) with chronic ment…
41y · Male·Fulminant sepsis (Klebsiella pneumoniae) with multi-organ failure complicating s…
A 41-year-old man with newly diagnosed severe Crohn's colitis was prescribed 6-mercaptopurine (6-MP) after only 5 days of hospital treatment. He had a homozygous TPMT gene deficiency (present in ~0.3% of population) that…
51y · Male·Complications of Recurrent Small Bowel Obstruction (palliated)
Matthew Clark, 51, with Down syndrome and chronic liver disease secondary to Hepatitis B, died from complications of recurrent small bowel obstruction. He had undergone emergency surgery in June 2018 for a perforated bow…
66y · Male·multiple organ failure associated with the combined effects of complications of …
Daniel Lahengking, a 66-year-old Indonesian visiting family in Esperance, was diagnosed with rheumatoid arthritis by locum GP Dr H. and prescribed methotrexate 5-10mg daily, a grossly excessive dose (normal: 7.5-20mg wee…
61y · Male·metastatic oesophageal neuroendocrine carcinoma
Terrence Wells, a 61-year-old prisoner, died from metastatic oesophageal neuroendocrine carcinoma in December 2018. Cancer was diagnosed in April 2018 after he reported difficulty swallowing, which was initially attribut…
45y · Male·Intra-abdominal haemorrhage due to ruptured spleen due to splenomegaly due to ci…
Hayward Rasmussen, a 45-year-old man with cirrhosis and severe splenomegaly, died from intra-abdominal haemorrhage due to ruptured spleen while in custody. He collapsed in prison after sustaining possible rib injuries fr…
86y · Male·multi-organ failure due to sepsis on a background of sacral pressure ulcer
An 86-year-old man died from multi-organ failure due to sepsis from a stage 4 sacral pressure ulcer after 61 days in a regional hospital. Critical failures included delayed pressure injury risk assessment (7 days overdue…
69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…
Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…
63y · Female·Intra-cerebral bleed secondary to thrombocytopenia in a person with prolymphocyt…
Josephine Troy, 63, died on 14 February 2006 at Bunbury Regional Hospital from an intracerebral bleed secondary to thrombocytopenia (platelet count of 1) arising from prolymphocytic leukaemia. She had been in remission f…
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