62y · Female·Unascertained
… coroner identified no clear departures from clinical standards. Key lessons include careful monitoring of sinus tachycardia in psychiatric patients, consideration of ECT safety protocols, and vigilance for sudden deter…
39y · Male·cardiomegaly
…hat his sudden collapse could not have been foreseen. Medical assessment on admission included ECG showing sinus tachycardia attributed to dehydration, chest X-ray, and bloods. Close observations continued until he was …
63y · Female·bile peritonitis as a complication from a laparoscopic cholecystectomy
… When the on-call surgeon was contacted by evening nursing staff with vital signs and ECG findings showing sinus tachycardia, she ordered only IV fluids and analgesia without clinical assessment. The coroner found the s…
23y · Male·Beta-phenylethylamine toxicity
A 23-year-old Army private died from beta-phenylethylamine toxicity after ingesting excessive quantities of this supplement purchased online. He had a history of low mood, fatigue, and anxiety, and had self-medicated wit…
47y · Male·Drug toxicity in the setting of restraint
Robert Ferrier, aged 47, died from drug toxicity in the setting of restraint after ingesting excessive quantities of prescription antidepressants and other medications during a mental health crisis. The expert panel conc…
29y · Male·Mixed drug toxicity (heroin, clozapine, zuclopenthixol, diazepam) in a morbidly …
Shane Jarrett, a 29-year-old with schizophrenia and substance abuse history, died from mixed drug toxicity (heroin, clozapine, zuclopenthixol, diazepam) complicated by morbid obesity. During psychiatric hospitalization, …
86y · Male·Complications post laparoscopic cholecystectomy
86-year-old man with acute gangrenous perforated cholecystitis underwent laparoscopic cholecystectomy on 2 October 2015, forty-two hours after admission. Severe bleeding from hepatic arterial branches required conversion…
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 partially dr…
33y · Female·Hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiop…
Melissa King, aged 33, died from hypoxic ischaemic encephalopathy following in-hospital cardiopulmonary arrest at Blacktown Hospital. She presented with severe malnutrition, electrolyte derangements including hyponatraem…
30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…
Karl Steinhauser, a 30-year-old man with schizoaffective disorder and polysubstance misuse, died from pulmonary thromboembolism on 12 March 2023 while under Mental Health Act care. After two weeks of increasingly challen…
28y · Female·hypoxic brain injury following cardiac arrest in association with pulmonary hype…
Petra Zele, a 28-year-old woman, died from hypoxic brain injury following cardiac arrest due to acute pulmonary embolism superimposed on chronic thromboembolic pulmonary hypertension. She presented to Fremantle Hospital …
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