9y · Female·Streptococcus pneumoniae and Candida albicans pneumonia and empyema in a girl wi…
Makayla Lee Wadeson, a 9-year-old autistic girl with ulcerative colitis on immunosuppressive therapy, presented to the emergency department with ear infection symptoms …
78y · Male·Complete transection of body sustained in single motor vehicle crash
… chronic health conditions including chronic kidney disease, diabetes with renal failure, and history of ulcerative colitis. The vehicle was mechanically sound. This death was entirely preventable through adherence to sp…
49y · Female·Widespread small and large bowel, splenic and hepatic infarction secondary to se…
… presented to the ED with months of abdominal pain, weight loss and diarrhoea, initially suspected to be ulcerative colitis. A CT scan on 26 August identified splenic infarcts but failed to recognize the critical arteria…
63y · Male·End stage ischaemic cardiomyopathy and chronic renal impairment
Nicola Spina, a 63-year-old male prisoner at Port Phillip Prison, died from end-stage ischaemic cardiomyopathy and chronic renal impairment on 17 July 2010. He presented to St Vincent's Hospital on 6 July 2010 with acute…
86y · Male·ischaemic and hypertensive heart disease
An 86-year-old man died of ischaemic and hypertensive heart disease while serving a prison sentence. He had multiple comorbidities including atrial fibrillation, congestive cardiac failure, and cirrhosis. The coroner exa…
67y · Male·Fulminant liver failure
A 67-year-old man presented to his GP with discoloured urine. Blood tests revealed acute liver toxicity but critical results were communicated via facsimile, with unclear timing of GP's review. The patient deteriorated r…
21y · Male·dilated cardiomyopathy
Dean Lovett, 21 years old, presented with fever, vomiting, cough and palpitations to his general practitioner on 6 September 2008. Dr G. identified clinical signs concerning for cardiac disease (tachycardia, finger clubb…
37y · Female·asphyxia due to hanging
A 37-year-old woman with major depression and Crohn's disease was admitted to hospital following a suicide attempt. She was discharged after less than two days following clinical improvement, against her husband's reserv…
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