14 results
27y · Female·Hanging
Ms YPM, a 27-year-old woman with a long history of borderline personality traits, depression, anxiety and eating disorder, died by hanging on 17 May 2020. In the preceding two weeks, she presented to Alfred Hospital foll…
53y · Male·disseminated malignant melanoma
A 53-year-old man died of disseminated malignant melanoma while incarcerated at Yatala Labour Prison. Initial excision of a large arm mole in November 2019 revealed Stage III melanoma. A January 2020 multi-disciplinary t…
61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed
A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…
86y · Female·Bradycardic arrest secondary to relative hypoperfusion while undergoing surgery …
An 86-year-old woman underwent elective surgery to excise a probable squamous cell carcinoma from her left hand with split-thickness skin grafting under local anaesthesia with intravenous sedation. She suffered an unexpe…
91y · Male·Complications of cerebrovascular and ischaemic heart disease in a man post anaph…
A 91-year-old man with known diltiazem allergy was prescribed diltiazem by a geriatrician despite documented allergy records. The geriatrician relied on the patient's verbal denial of allergies despite significant dement…
66y · Male·bronchopneumonia in a man with invasive sarcoma-like tumour of the head, with te…
Benedict Chifley David Candy, a 66-year-old sentenced prisoner, died from bronchopneumonia complicating invasive sarcoma-like tumour of the head with terminal palliative care. He had a recurrent Merkel cell carcinoma tha…
0y · Female·Right ventricular failure secondary to pulmonary atresia with ventricular septal…
Armani El-Sayegh was a seven-month-old infant who died from right ventricular failure secondary to complex congenital heart disease (pulmonary atresia with ventricular septal defect and major aortopulmonary collateral ar…
72y · Male·exsanguination (blood loss) from severed femoral artery
Stephen Maxwell Powell, a 72-year-old man with schizophrenia, died by exsanguination from a self-inflicted femoral artery laceration. He was discharged from psychiatric inpatient care on a community treatment order on 14…
87y · Female·combined effects of ischaemic heart disease and chronic obstructive pulmonary di…
Epenesa Pahiva, 87-year-old resident with dementia at an aged care facility, suffered severe chemical burns from inappropriate bleach treatment prescribed by dermatologist Dr B.. The coroner found the treatment itself (h…
77y · Male·Complications of methotrexate toxicity in a man with chronic renal impairment, c…
A 77-year-old man with chronic kidney disease, COPD, and mild cardiac failure died from methotrexate toxicity after a GP prescribed it at an inappropriate daily dose (5mg daily) for psoriasis without baseline blood tests…
60y · Female·Complications of metastatic melanoma in the setting of neck of femur fracture fo…
Susan Ruth Lovell, a 60-year-old woman, died from complications of metastatic melanoma in the setting of a neck of femur fracture sustained during a fall. A skin lesion on her left calf, noted in January 2010, was clinic…
14y · Female·Hanging
Taylah Mahon, a 14-year-old girl, died by hanging in August 2009. She was being treated with isotretinoin (Roacutane) for severe acne by a dermatologist who reviewed her regularly. Expert opinion confirmed isotretinoin's…
45y · Male·metastatic malignant melanoma
Craig Lingwood, a 45-year-old prisoner, died from metastatic melanoma in May 2011. He first complained of a suspicious mole (red, itchy, bleeding) in 2005-2006, but the prison doctor (Dr C.) assessed it as benign in Augu…
24y · Female·hypoxic brain injury following unexplained cardiorespiratory arrest
A 24-year-old female with brittle Type 1 diabetes and multiple comorbidities presented to Joondalup ED with a rapidly spreading blistering rash on 3 September 2009. Dr C. appropriately identified a potentially serious de…
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