70y · Male·Complications of Ischaemic cardiomyopathy and Chronic Obstructive Pulmonary Dise…
Stephen Pitty, aged 70, died from complications of ischaemic cardiomyopathy and chronic obstructive pulmonary disease whilst in custody at Long Bay Correctional Centre. He had significant cardiac history including …
82y · Male·Ischaemic cardiomyopathy resulting from coronary atherosclerosis (with previous …
An 82-year-old man with longstanding cardiac disease and renal failure died in custody from acute heart failure. He had been imprisoned for 3 years with well-documented cardiac…
67y · Female·choking and ischaemic heart disease
Patricia Ann Fidge, 67, died at The Queen Elizabeth Hospital from choking and ischaemic heart disease. She was admitted with delirium, hypernatremia, and multiple comorbidities including COPD and sleep apnoea. While eati…
76y · Female·pulmonary embolism due to carcinomatosis
…ospital with shortness of breath and was initially diagnosed with community-acquired pneumonia and later pulmonary oedema. Both diagnoses were incorrect. She had widespread cancer (carcinomatosis) with multiple pulmonar…
Three separate cases: (1) Ronald Grundy - advanced atherosclerotic coronary vasc…
…s provided appropriately in the prison facility per his wishes. Ian Smith (46) died of congestive cardiac failure and atherosclerotic cardiovascular disease after a lifetime of complex cardiac problems; he received appr…
46y · Female·Dilated cardiomyopathy (acute complication with sudden cardiac arrhythmia)
A 46-year-old woman with bipolar/schizoaffective disorder, poorly controlled type 2 diabetes, morbid obesity, severe obstructive sleep apnoea, and pulmonary hypertension died from acute dil…
68y · Male·Pulmonary thromboembolus secondary to deep vein thrombosis
Ronald Wood, a 68-year-old with complex medical history including prior pulmonary emboli, was treated for rectal cancer requiring chemotherapy and major surgery. Warfarin anticoagulation…
64y · Female·Acute bronchopneumonia in a woman with liver failure
Patsy Chubby, 64, died from acute bronchopneumonia complicated by terminal liver failure and multiple chronic conditions (cardiac cirrhosis, heart failure, COPD, diabetes, pulmonary hypertension…
56y · Male·Pulmonary thromboemboli due to deep vein thrombosis due to immobility due to hea…
A 56-year-old concreter died from pulmonary embolism secondary to deep vein thrombosis and immobility following a severe head injury sustained when …
81y · Male·Chronic lung disease (severe COPD) with atherosclerotic cardiovascular and valvu…
…spiratory depressant medications (opioids, benzodiazepines) are contraindicated in COPD patients at risk of type 2 respiratory failure; (3) interhospital transfers require consultant-to-consultant handover and explicit d…
36y · Male·Complications of morbid obesity, including cardiac enlargement, aspiration of ga…
… (183.5 kg, BMI 45.3). He was discharged from hospital on 14 January 2019 after admission for respiratory failure and returned to Bayview Lodge, a supported accommodation facility without medical oversight. He died two …
81y · Male·Aspiration pneumonia complicating end stage fronto-temporal dementia on a backgr…
…fronto-temporal dementia with chronic obstructive lung disease, ischaemic heart disease and chronic renal failure. He was detained under the Mental Health Act following behavioural deterioration after medication changes…
57y · Female·acute pulmonary embolism
Sandra McRae, age 57, died from pulmonary embolism on day 13 of hospitalisation following pelvic fractures sustained in a motor vehicle accident. …
47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…
Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had CO…
74y · Male·small intestinal ischaemia caused by aortic atherosclerosis
…chaemic bowel was not diagnosed until 9pm when he was critically ill with septic shock and multiple organ failure. By then, his entire small intestine was dead and surgery could not save him. Key failures included: not …
57y · Male·Ischaemic and valvular heart disease
David Charles Shaw, 57, died of ischaemic and valvular heart disease with severe coronary artery atherosclerosis. He was enrolled in MePACS, a medical alarm service requiring daily button activation between 6-11am. When …
68y · Female·Anaphylaxis in a woman with atherosclerotic cardiovascular disease and emphysema
A 68-year-old woman with severe COPD and undiagnosed atherosclerotic heart disease underwent cataract surgery at Northam Hospital. Post-operatively, she was prescribed Diamox (acetazolamide), a sulphonamide medication. D…
48y · Male·myocardial infarction due to coronary atherosclerosis (medically treated)
Garnett Mickelo, aged 48, died from myocardial infarction due to coronary atherosclerosis while in custody at Woodford Correctional Centre on 24 November 2012, shortly after discharge from Princess Alexandra Hospital fol…
55y · Male·Subdural haematoma in a man with diabetes mellitus and chronic kidney disease (r…
…redictable. The coroner found appropriate medical care was provided. Key systemic issues identified were: failure to place him on the Terminally Ill List upon admission despite complex health needs; delayed family notif…
64y · Male·Septic shock secondary to urosepsis (Pseudomonas and Stenotropomonas maltophilia…
…ze sepsis or clinical deterioration. Critical errors included: misinterpreting elevated troponin as renal failure alone, not initiating antibiotics despite infection signs, not correcting hyperkalaemia, and transferring…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.