223 results
84y · Male·bronchopneumonia complicating C2 odontoid fracture (palliated) due to fall on a …
Wayne Malcolm Clark, aged 84, with advanced Alzheimer's and vascular dementia, fell in a secure residential aged care facility and sustained a C2 odontoid fracture. He died on 23 August 2023 from bronchopneumonia complic…
74y · Male·Pulmonary thromboembolism due to right deep vein thrombosis
Richard Holden, aged 74, presented to his GP Dr C. multiple times in August 2020 with progressive shortness of breath and wheeziness. Dr C. diagnosed and treated asthma despite worsening symptoms and failure to respond t…
47y · Female·head injury
Sohaila Mohammadi (47) was killed in a motor vehicle collision caused by driver Tristan Mourant, who had bilateral retinal dystrophy and was advised by three medical professionals not to drive. However, none of the docto…
70y · Male·metastatic gastric adenocarcinoma
A 70-year-old man with prior bladder cancer was undergoing routine CT surveillance. Stomach cancer signs were clearly visible on February 2017 and February 2018 CT scans but failed to be detected by consulting radiologis…
61y · Male·bronchopneumonia complicating cerebrovascular accident due to cardioembolism on …
A 61-year-old man with a mechanical aortic valve underwent colonoscopy requiring temporary warfarin cessation. Following the procedure, he was discharged with a plan to recommence warfarin but without clear postoperative…
[77, 80, 55]y · Unknown·Multiple injuries from motor vehicle collision
A motor vehicle collision on the Princes Highway near Suttontown killed three adults when a 16-year-old driver with significant neurological conditions momentarily lost concentration while ascending a hill. The driver ha…
78y · Female·urinary tract infection and pneumonia on a background of facial fractures and de…
A 78-year-old woman with mixed dementia living in aged care suffered an unwitnessed fall on 22 March 2023, sustaining facial fractures and eye laceration. The fractures were not identified during her initial hospital ass…
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…
Male·Hemant Chadha: acute on chronic pneumonia (mycoplasma pneumoniae). Sachintha Bat…
Two young men died after repeated ED presentations were not appropriately managed. Hemant Chadha (38) died of acute pneumonia complicated by possible neurological involvement after being discharged from Lyell McEwin Hosp…
44y · Male·unascertained
Matthew Benjamin Holding, aged 44, died suddenly in prison on 2 January 2023. He had schizophrenia managed with antipsychotics and severe obesity (BMI 41.6). In December 2022, he showed signs of significant deterioration…
79y · Male·Urinary tract infection with E coli bacteraemia on a background of ischaemic hyp…
A 79-year-old man with multiple comorbidities attended Whyalla Hospital ED following a fall. Paramedics documented concerning vital signs (tachypnoea, tachycardia, low oxygen saturation, fever) and a history suggestive o…
88y · Female·Acute on chronic renal failure due to dehydration on a background of Lewy body d…
An 88-year-old woman with Lewy body dementia, Parkinson's disease and congestive cardiac failure died from acute kidney injury precipitated by severe dehydration in aged care. June 2020 blood tests showed mild hypernatra…
25y · Male·hanging
Logan Brown, a 25-year-old man on home detention bail, died by hanging. He had a complex psychiatric history including borderline personality disorder, polysubstance use disorder, and chronic suicidal ideation dating fro…
27y · Male·heroin toxicity
A 27-year-old man died from heroin toxicity while on home detention bail. He had a history of depression, anxiety, and substance use (cannabis, methamphetamine, heroin). During home detention, he was compliant, engaged w…
36y · Male·acute neck compression due to hanging
Paul Douglas Gifford, aged 36, died by hanging while on home detention bail. He had a long history of substance abuse (methamphetamine, opioids), mental health issues including borderline personality disorder, childhood …
66y · Male·multiple injuries sustained in motor vehicle collision
A 66-year-old cyclist was struck and killed from behind by a driver with left absolute homonymous hemianopia (left-sided visual field loss) who was not scanning to compensate for his disability. The driver had suffered a…
89y · Female·acute-on-chronic renal failure on a background of ischaemic heart disease, hyper…
An 89-year-old Aboriginal woman with chronic renal impairment and congestive cardiac failure was prescribed gentamicin intramuscularly for a urinary tract infection caused by Klebsiella aerogenes. Gentamicin is nephrotox…
80y · Female·Fractured left neck of femur on a background of rectal carcinoma and dementia
An 80-year-old woman with dementia and undiagnosed rectal carcinoma died from complications of a fractured left neck of femur sustained during a fall in her aged care facility's memory support unit. She had sustained thr…
48y · Female·multiple drug toxicity consisting of flecainide, lorazepam and diazepam
A 48-year-old woman died from multiple drug toxicity (flecainide, lorazepam, diazepam) following a deliberate overdose. She was located by police after a search and detained under the Mental Health Act. Critical delays o…
43y · Male·methylamphetamine and heroin toxicity
A 43-year-old man died from methylamphetamine and heroin toxicity while on home detention bail. He had a complex psychiatric history including depression, psychosis, PTSD, and polysubstance use disorder, with previous su…
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