91y · Female·pulmonary thromboembolism and subcutaneous abscess formation complicating pressu…
…woman died from pulmonary thromboembolism and abscess formation complicating untreated ankle fracture and pressure sores. She had sustained a fracture-dislocation of her right ankle after a fall, which she refused medica…
55y · Male·Staphylococcal sepsis, complications of pressure sores and hypostatic pneumonia,…
…ngs included inadequate transition planning without continuity of known carers, lack of staff training in pressure sore identification and prevention, poor integration between community health services, absence of pre-tr…
88y · Female·pulmonary thromboembolism due to fractured right femur due to a fall
…ar evidence of severe pain and immobility. The patient remained bedbound in filthy conditions, developing pressure sores and malnutrition. Hospital staff provided appropriate, multidisciplinary care including prophylacti…
26y · Female·Streptococcal Sepsis resulting from Skin Ulceration and complications of Cerebra…
… palsy, epilepsy, and intellectual disability, died on 28 June 2007 of Streptococcal sepsis from infected pressure ulcers. She was cared for at home by her mother Daphne and sister Jenna. Following her father's death in …
83y · Female·Combined effects of severe malnutrition and infection (septicaemia secondary to …
Mrs Clark, 83, died from severe malnutrition and infection including septicaemia from an infected sacral pressure ulcer that had existed for 7 months. She was admitted to hospital in a deplorable state with severe press…
70y · Female·Aspiration pneumonia, associated with Huntington's disease
…yndrome causing agitation and increased aspiration risk, insufficient fluid and nutritional support, poor pressure area management, and delayed medical review when her condition deteriorated. The coroner found care was i…
77y · Female·Complications following a recent fracture and surgical repair of the right hip i…
…ent aimed at hypotension may have contributed to pulmonary/cardiac fluid overload evident at autopsy. (6) Pressure sores developed rapidly preoperatively and remained painful. The case illustrates that elderly patients w…
81y · Male·metastatic rectal adenocarcinoma with infected necrotic sacral ulcer
…cal failures included: inappropriate prolonged physical restraint (up to 17 hours daily) that exacerbated pressure injuries; lack of specialised wound care when the wound nurse was unavailable; inadequate nutritional sup…
69y · Male·septic shock due to infected decubitus ulcers complicated by osteomyelitis
A 69-year-old man with Parkinson's disease died from septic shock caused by infected pressure ulcers (stage 4 decubitus ulcers with osteomyelitis) that developed in aged care. Pressure sores appeared…
59y · Male·Respiratory failure with paraplegia as a significant contributing factor
Michael Ruawai Robin, a 59-year-old man with paraplegia and incomplete quadriplegia (C4-C6), died from respiratory failure at Werribee Mercy Hospital on 22 June 2023. He presented with a rash and urinary tract infection …
75y · Female·organ failure due to sepsis, likely from infected pressure sores, in the context…
…olled diabetes and ischaemic heart disease, died from septic shock secondary to extensive infected sacral pressure wounds. She received home care through KinCare for approximately 9 months, during which her condition det…
72y · Female·Hanging
Chang Ying Xu, a 72-year-old Chinese-speaking woman with severe spinal cord compression, chronic pain, and depression, died by hanging during respite care at an aged care facility. While her depression history and multip…
32y · Male·Aspiration pneumonia and reflux oesophagitis
Timothy Luke Rubenach, aged 32, died of aspiration pneumonia following severe reflux oesophagitis. He had profound intellectual disability and drug-resistant epilepsy from meningococcal infection at 5 months. His parents…
57y · Female·starvation due to insufficient food intake
Patricia Iliev, a 57-year-old woman, died from starvation after progressively restricting her food intake over months while immobilised by chronic back pain. She had a gastrointestinal stromal tumour and advanced lung di…
Female·bilateral acute bronchopneumonia
Ivy Pearl Ghobrial died from bilateral acute bronchopneumonia at a nursing home in September 2001, following a hypoxic brain injury sustained from a hanging attempt in March 2000. The coroner found the death resulted ine…
71y · Female·Complications of cerebral palsy
Lorraine Earl, aged 71, died from complications of cerebral palsy at Wantirna Hospital following a palliative care pathway initiated after severe dysphagia developed during a hospital admission. The Disability Services C…
53y · Male·aspiration pneumonia on a background of oesophageal cancer and ischaemic heart d…
Anthony Stephen Gibson, aged 53, died in hospital from aspiration pneumonia secondary to oesophageal cancer and ischaemic heart disease. He was serving a prison sentence and was shackled to his bed throughout most of his…
48y · Female·Unascertained; presumed sudden cardiac arrhythmia
A 48-year-old woman with cerebral palsy, intellectual disability, and multiple comorbidities died unexpectedly in residential care. Post-mortem examination showed acute pulmonary oedema and intra-alveolar haemorrhage wit…
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