66y · Female·aspiration pneumonitis and gangrenous necrosis of both feet
A 66-year-old woman with untreated rheumatoid arthritis, severe lower limb cellulitis with gangrenous necrosis, and a personality disorder died from a…
75y · Male·Complications of multiple cardiac and respiratory comorbidities
…. He had pulmonary arterial hypertension, right ventricular failure, chronic lung disease, diabetes, and rheumatoid arthritis. Following aspiration pneumonia in April 2021, he was admitted to the prison medical unit for …
53y · Male·immersion (drowning)
…gulatory requirements, carried no safety equipment (flares, EPIRB, radio), had deteriorating health from rheumatoid arthritis affecting balance and strength, launched in rough conditions (14+ knot winds, 2.5-metre seas) …
45y · Female·Cerebrovascular accident
Ms L, a 45-year-old woman with Down syndrome and multiple comorbidities including chronic rheumatoid arthritis, suffered a massive right basal ganglia cerebral haemorrhage with intraventricular extension o…
54y · Female·Pneumonia - chest sepsis
Kim Elizabeth Taylor, a 54-year-old NDIS participant with quadriplegia and tracheostomy, died from pneumonia and chest sepsis at Austin Hospital. She had experienced recurrent ventilator-associated pneumonia, bronchiecta…
39y · Female·mixed prescription drug and alcohol toxicity (ethanol, tapentadol, tramadol, pro…
…r. Key clinical lessons: Ms O'Shea had chronic complex medical conditions (breast cancer post-treatment, rheumatoid arthritis, sarcoidosis, depression, anxiety) with previous overdose attempts and suicidal ideation. She …
37y · Female·unlawful killing
…ime of disappearance, she was rebuilding her life—working, studying, and developing independence despite rheumatoid arthritis and alcohol misuse. The coroner found that Kath was unlawfully killed and her remains secretly…
68y · Female·Multi-organ failure associated with septic shock following duodenal perforation …
…records access, and TOPAS computer system limitations, while noting the deceased's steroid treatment for rheumatoid arthritis increased her vulnerability to perforation and sepsis.
76y · Male·Sepsis, with osteomyelitis and infective endocarditis
…ntenced prisoner with complex medical history including atrial fibrillation, valvular heart disease, and rheumatoid arthritis, died from sepsis caused by osteomyelitis and infective endocarditis. Over 9 months, he experi…
79y · Female·medication related cardiac arrest (verapamil and propranolol) in a patient with …
Mrs Patricia Croxon, a 79-year-old admitted with community-acquired pneumonia, died from medication-related cardiac arrest caused by verapamil and propranolol. The verapamil was charted in immediate release form when she…
98y · Female·subarachnoid haemorrhage associated with closed head injury from fall
A 98-year-old woman died from a subarachnoid haemorrhage following a fall at home where she tripped on her walker. She was found 6 hours after the fall and admitted to hospital, but scans revealed non-survivable brain in…
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: …
62y · Male·Multi-organ failure following surgical repair of ruptured abdominal aortic aneur…
Robert Paul Rodda, a 62-year-old long-term prisoner with extensive medical comorbidities including ischaemic heart disease, COPD, and a known abdominal aortic aneurysm (AAA), presented with chest pain in September 2015. …
62y · Female·Multiple (head, chest and limb) injuries
A 62-year-old woman driving on the Tasman Highway in Tasmania was affected by sun glare while approaching a blind left-hand curve. She shielded her eyes with her left hand, causing her vehicle to cross double white centr…
42y · Female·Subarachnoid haemorrhage as a consequence of rupture of saccular aneurysm of the…
Kerry-Ann Long, a 42-year-old woman in custody at Brisbane Women's Correctional Centre, collapsed suddenly on 3 February 2009 from rupture of a previously undiagnosed anterior communicating artery aneurysm causing subara…
55y · Female·exsanguination due to a gunshot wound to the upper left chest
A 55-year-old woman with a 20-year history of depression died from a self-inflicted gunshot wound. She had attempted suicide twice in 2019 (July and December) and was managed by her general practitioner and Tasmania Heal…
68y · Female·mixed prescription drug toxicity (oxycodone, metoprolol, diazepam)
Ms Heraghty, a 68-year-old woman with multiple comorbidities including obesity (BMI 47.3), atrial fibrillation, COPD, and severe chronic pain, died from mixed prescription drug toxicity (oxycodone, metoprolol, diazepam) …
61y · Male·Pneumonia
Kenneth Morrison, a 61-year-old man with Down's syndrome, dementia and multiple comorbidities, died from pneumonia following hospitalisation at Casey Hospital in March 2008. Community Residential Unit (CRU) carers raised…
60y · Female·undetermined
Margaret Elizabeth Hills, a 60-year-old woman with chronic pain and depression from a work-related spinal injury, disappeared on 2 February 2010 from her home in Katoomba, NSW. Her skeletal remains were discovered nearly…
84y · Male·Respiratory failure complicating hospital acquired pneumonia following surgical …
An 84-year-old man died from respiratory failure due to hospital-acquired pneumonia following surgery for recurrent mandibular squamous cell carcinoma. Key clinical lessons: (1) Advanced Care Plans (ACPs) must be activel…
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