87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
90y · Female·Choking
A 90-year-old woman with dysphagia died from choking after consuming thin fluid (coffee) against medical recommendation. She had been reviewed by a speech pathologist on 15 November 2024 who recommended thick fluids only…
85y · Male·Sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left …
An 85-year-old man died in custody from sepsis due to Staphylococcus aureus bacteraemia arising from septic arthritis of the left shoulder, on a background of congestive heart failure. While receiving generally adequate …
61y · Male·Natural causes unascertained
David Evan Wild, 61 years old, died of natural causes of unascertained origin while residing in specialist disability accommodation. He had frontal temporal dementia diagnosed in 2020 and required 24/7 care. He experienc…
84y · Male·The available evidence does not allow for any finding to be made as to the cause…
An 84-year-old man with Alzheimer's dementia and a history of wandering left his home on 15 September 2017 and was never found alive. The coroner determined he is deceased, likely died within days of going missing in bus…
85y · Male·Aspiration pneumonia in the setting of ischaemic heart disease, type 2 diabetes …
An 85-year-old man died of aspiration pneumonia in a prison healthcare setting while receiving palliative care. He had experienced a stroke two years prior resulting in cognitive decline and required assistance with all …
59y · Female·Aspiration pneumonia and urosepsis complicating Alzheimer's dementia in setting …
Michelle Anne Leiper, aged 59 with Down syndrome and Alzheimer's dementia, died from aspiration pneumonia and urosepsis. She had significant dysphagia and was largely bedbound in her final years. After a February 2025 ho…
Unknown·Choking; Mr Gesios: large bolus of bread and scrambled eggs causing complete air…
Two aged care residents died from choking on bread despite being prescribed minced and moist diets that prohibited regular bread. Mr Gesios was fed bread dipped in Milo by an inexperienced AIN without adequate supervisio…
70y · Female·Multi-organ dysfunction complicating sepsis of unknown origin in setting of Alzh…
Suzanne Craig Morter, aged 70, with Down Syndrome and Alzheimer's dementia died from sepsis with multi-organ dysfunction of unknown origin. She collapsed at home on 9 May 2024 and was taken to hospital where investigatio…
84y · Male·Complications of fracture left humerus neck due to fall due to hyperactive delir…
An 84-year-old man with Alzheimer's disease and dementia-related behaviours developed a urinary tract infection causing acute delirium, atrial fibrillation, and multiple falls. After presenting to the emergency departmen…
60y · Male·Aspiration pneumonitis in a man with Down Syndrome
Marcello Sardo, a 60-year-old man with Down syndrome and early-onset Alzheimer's dementia, died from aspiration pneumonitis at Austin Hospital. He had been receiving palliative care in the community following his geriatr…
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…
45y · Male·Environmental exposure and dehydration
A 45-year-old Aboriginal man with severe cognitive impairment (6.5-year-old equivalent English comprehension), traumatic brain injury, epilepsy and multiple medical conditions died from environmental exposure and dehydra…
87y · Female·right thigh haematoma as a consequence of a periprosthetic fracture of the right…
An 87-year-old woman with multiple comorbidities (diabetes, atrial fibrillation, peripheral vascular disease) sustained a periprosthetic fracture requiring distal femur replacement. She deteriorated significantly during …
39y · Male·Mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) with contribut…
Kevin Thomas Maloney, a 39-year-old man with complex mental health conditions and substance use disorder, died from mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) while residing in a supported resident…
70y · Male·unascertained - likely exposure or natural causes such as a medical episode
John Frylinck, a 70-year-old man with Alzheimer's disease and poorly controlled type 2 diabetes, disappeared on 18 January 2024 while walking at Mundaring Sculpture Park. Despite an extensive search involving 120 volunte…
92y · Male·Consequences of accidental fall at RACF: post-operative delirium, left femoral i…
A 92-year-old man resident in an aged care facility sustained an unwitnessed fall resulting in left hip fracture, requiring surgical fixation. He developed post-operative delirium and died 8 days later. The coroner ident…
Male·Little Brother: multi-organ dysfunction due to hypothermia with contributing con…
Two Aboriginal brothers with chronic alcohol use disorder and cognitive impairment died in July and September 2023 in Alice Springs Hospital. Both had adult guardianship orders, NDIS packages, and aged care assessments r…
64y · Male·Pneumonia secondary to ischaemic cerebrovascular incidents, hypertension, and at…
Yan Jin, a 64-year-old man with history of stroke, hypertension, and atrial fibrillation, was admitted to hospital after a witnessed fall from bed. Despite no fractures, he remained hospitalised for discharge planning gi…
70y · Female·pneumonia and post-surgical course following repair of neck of femur fracture, i…
Susan Mitchelmore, a 70-year-old woman with multiple comorbidities including COPD, ischaemic heart disease, diabetes, and bipolar disorder, was a resident in an aged care facility under a Mental Health Act Treatment Orde…
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