72y · Male·Metastatic renal cell carcinoma
Daniel Hourigan, a 72-year-old man with intellectual disability and metastatic renal cell carcinoma, died in palliative care after admission on 29 April 2011. He had widespread metastases inv…
60y · Female·Renal carcinoma
…ladys Vincent, a 60-year-old woman with intellectual disability residing in disability services, died from renal carcinoma. She had been diagnosed with kidney cancer two years prior and was under palliative care through…
71y · Male·metastatic papillary renal cell carcinoma
Robert Bell-Williams, aged 71, died from metastatic papillary renal cell carcinoma while in lawful custody at Long Bay Hospital on 1 February 2024. Imprisoned since 2012, he …
57y · Male·Gastrointestinal haemorrhage due to a duodenal ulcer in the setting of recent ne…
…from gastrointestinal haemorrhage due to a duodenal ulcer eight days after undergoing left nephrectomy for renal carcinoma. Autopsy revealed approximately 900ml of clotted blood in the stomach and bowel from a bleeding …
42y · Male·disseminated metastatic renal cell carcinoma
A 42-year-old prisoner died from disseminated metastatic renal cell carcinoma. Renal cancer was identified by ultrasound in September 2006 and confirmed by CT scan. Surg…
55y · Male·Renal cell carcinoma (brain metastasis)
…tely transferred to hospital where MRI imaging revealed a large right frontal brain tumour with metastatic renal cell carcinoma. He underwent uncomplicated craniotomy and tumour resection on 25 September 2014. Despite s…
38y · Male·metastatic poorly differentiated carcinoma on a background of delirium and schiz…
Anthony Sissons, aged 38, died of metastatic renal carcinoma while under a Mental Health Act inpatient treatment order. He presented to hospital on three sep…
57y · Male·Complications of congenital rubella (palliated)
…needs including intellectual disability, deafness, blindness, dysphagia, epilepsy, and recent diagnosis of renal cell carcinoma. In September 2023, his health deteriorated with multiple hospital admissions for seizures,…
79y · Female·pulmonary oedema and electrolyte imbalance, both secondary to renal failure
Mrs Mulvinskas, a 79-year-old with end-stage renal disease, renal carcinoma, diabetes, and cardiac failure, died from pulmonary oedema and electrolyte imbala…
74y · Male·disseminated carcinoma (widespread cancer); specifically haemorrhage into right …
Ronald Smallwood, a 74-year-old man with chronic paranoid schizophrenia and renal cancer, died in hospital from disseminated carcinoma. The key clinical lesson relates to institutional kno…
56y · Male·disseminated malignancy – known non-small cell carcinoma of lung
…aham, a 56-year-old Aboriginal man with severe COPD and lung cancer, died of disseminated non-small cell carcinoma while in prison custody receiving palliative care. The coroner found his medical care was of high standa…
64y · Male·Ischaemic bowel and spleen infarction secondary to occlusion of splenic artery a…
…ips incorrectly placed on the splenic and superior mesenteric arteries during laparoscopic nephrectomy for renal cell carcinoma. The surgeon misidentified major blood vessels in the setting of extensive fibrotic tissue …
50y · Male·carcinomatosis due to metastatic, poorly differentiated renal cell carcinoma unc…
Michael Sfyris, a 50-year-old prisoner, died of metastatic renal cell carcinoma in April 2016. A CT scan performed in September 2015 revealed an adrenal lesion but the rad…
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 symp…
71y · Male·Organ failure in an elderly man receiving palliative medical care for renal fail…
Gheorghe Gruici, a 71-year-old life-sentenced prisoner, died of organ failure from chronic renal failure, infective endocarditis, and chest infection. Over 15 years in custody, he developed multiple como…
81y · Male·haemorrhage from metastatic squamous cell tumour of the right axilla
An 81-year-old man with extensive comorbidities (cardiac failure, COPD, diabetes, renal failure) presented with a right axillary squamous cell carcinoma with metastases. He was admitted for pall…
48y · Male·large cell carcinoma of lung with metastases
Neal Richardson, a 48-year-old man serving a 28-year prison sentence, died of large cell carcinoma of lung with metastases while receiving palliative care at Prince of Wales Hospital. He had presented to…
55y · Male·Multi-system failure complicating intra-operative haemorrhage due to inadvertent…
…following inadvertent ligation of the superior mesenteric artery (SMA) during laparoscopic nephrectomy for renal cell carcinoma. Dr L. misidentified the SMA for the left renal artery and applied insufficient clipping. A…
82y · Male·Acute myocardial infarction caused by ischaemic heart disease
…Prince of Wales Hospital. He had significant comorbidities including severe triple vessel disease, chronic renal impairment, interstitial lung disease, and Alzheimer's disease. An Advanced Care Directive establishing a …
76y · Male·Small bowel obstruction and acute renal failure, due to or as a consequence of m…
Adrian Adams, aged 76, died in Princess Alexandra Hospital from small bowel obstruction and acute renal failure secondary to metastatic colorectal cancer. He was serving an eight-year sentence for sexual offenc…
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