19 results
46y · Female·Hepatic encephalopathy due to decompensated Child-Pugh C cirrhosis and meningiti…
This combined coronial finding examines three deaths at the Centre for National Resilience (CNR), a COVID-19 quarantine facility in Howard Springs. Ms Dick died from rapidly progressive melioidosis. David Hardy died from…
22y · Unknown·sudden death associated with volatile substance inhalation (butane and propane)
A 22-year-old Yolngu person with a well-documented history of volatile substance abuse (VSA) and mental illness was involuntarily admitted to Royal Darwin Hospital for acute psychosis. Due to COVID-19 bed-block, they wer…
80y · Male·metastatic oesophageal cancer
Josef Lear, an 80-year-old prisoner, died of metastatic oesophageal cancer at the Royal Darwin Hospital Hospice on 7 March 2021. He presented with progressive dysphagia, cough, and weight loss in mid-2020, which was appr…
62y · Male·hepatic encephalopathy due to acute renal failure
Ronnie Pangata Nelson, a 62-year-old Aboriginal man, died in Alice Springs Hospital from hepatic encephalopathy due to acute renal failure. He had longstanding chronic diseases including cirrhosis, hepatitis B and C, dia…
41y · Male·respiratory arrest secondary to advanced metastatic breast cancer
Ray Jabaltjari Gibson was a 41-year-old Aboriginal man with advanced metastatic breast cancer who died of respiratory arrest while in prison custody. He had been diagnosed with breast cancer in 2013 while imprisoned and …
65y · Male·Congestive Cardiac Failure secondary to Ischaemic Heart Disease due to Non-Small…
Kevin John Steel, a 65-year-old Aboriginal man with advanced non-small cell lung cancer, ischaemic heart disease, atrial fibrillation, and multiple comorbidities, died in Alice Springs Hospital from congestive cardiac fa…
59y · Male·Cardiac arrest caused by Ischaemic Heart Disease
Angus Dixon, a 59-year-old Aboriginal man with ischaemic heart disease, diabetes, and a history of paranoid psychosis, died from acute myocardial infarction while an involuntary mental health patient at Alice Springs Hos…
29y · Female·multi-lobe community acquired pneumonia and respiratory failure
Clare Louise Harrison, a 29-year-old woman with long-standing anorexia nervosa diagnosed at age 17, died from community-acquired pneumonia and respiratory failure after a final 21-day admission to Alice Springs Hospital.…
63y · Male·cancer in the left lung metastatic to the heart, right lung, liver, pancreas and…
Victor Albert Campbell, a 63-year-old man remanded in custody for serious criminal offences, was incarcerated at Alice Springs Correctional Centre on 10 April 2013. He was assessed by medical staff and seen by a doctor p…
42y · Male·Sudden cardiac death in the context of schizophrenia
Anthony Graham Greig Faulkner, a 42-year-old man with longstanding schizophrenia (formerly diagnosed as bipolar disorder), died suddenly on 23 September 2013 while an involuntary psychiatric patient at Cowdy Ward, Royal …
46y · Male·Acute hypoxic brain damage resulting from intentional self-inflicted hanging
A 46-year-old male prisoner died from acute hypoxic brain damage following self-inflicted hanging in custody. He had a history of physical health issues including HIV and mental health concerns including anger management…
51y · Male·pneumonia secondary to hepatocellular carcinoma and chronic liver disease
A 51-year-old Aboriginal man died from pneumonia secondary to hepatocellular carcinoma and chronic liver disease while in custody. He had presented to hospital on 26 May 2010 with abdominal pain and imaging showed a larg…
49y · Male·Acute bronchopneumonia as a consequence of recent intracranial and intra-cerebra…
Peter Raymond Jacobs, a 49-year-old Aboriginal man with severe cirrhosis and chronic alcohol abuse, was apprehended by police on 5 April 2008 for intoxication. He fell twice before custody (hitting his head at Town Hall …
64y · Female·acute subdural haemorrhage sustained after a fall on Ward 4A
Margaret Winter, 64, died from acute subdural haemorrhage following a fall on Ward 4A on 13 December 2006. She had been admitted with decompensated liver disease. Her falls risk was misclassified as low when it should ha…
30y · Male·diffuse alveolar damage, a complication of bacterial endocarditis
Freddie Peterson, a 30-year-old Aboriginal man from Papunya, died in custody from bacterial endocarditis complicated by diffuse alveolar damage. He was imprisoned for nine months and presented to the prison medical centr…
43y · Female·unknown
Rita Anderson, a 43-year-old Aboriginal woman with chronic alcohol-related organic brain damage, was admitted to Royal Darwin Hospital in March 2002 for stabilization and placement planning. Unable to safely live indepen…
67y · Male·acute renal failure with associated severe acidosis and hyperkalemia
A 67-year-old Aboriginal male with dementia was discharged from Royal Darwin Hospital on 4 November 2001 following cystoscopy and bladder neck incision for suspected obstruction. Critical communication failures meant the…
57y · Male·carcinoma of the right lung
Alfred Firth Thorpe, a 57-year-old man imprisoned for manslaughter, died of carcinoma of the right lung whilst in custody. He had declined radiotherapy for throat cancer in 1999, which may have prevented recurrence. Lung…
74y · Male·disseminated carcinoma (widespread cancer); specifically haemorrhage into right …
Ronald Smallwood, a 74-year-old man with chronic paranoid schizophrenia and renal cancer, died in hospital from disseminated carcinoma. The key clinical lesson relates to institutional knowledge rather than direct patien…
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