38 results
1y · Female·Rapidly developing Streptococcus pneumoniae infection leading to invasive pneumo…
Arianna Maragol, a 16-month-old girl, died from rapidly developing Streptococcus pneumoniae infection leading to invasive pneumococcal disease while in childcare on 24 August 2018. Key clinical lessons emerged: (1) Pneum…
43y · Male·Bilateral pulmonary thrombo-emboli; contributory factors included obesity, coron…
Paul Harris, a 43-year-old Aboriginal man, died from bilateral pulmonary emboli while hospitalized at Hay District Hospital. He presented in September 2019 with pneumonia and Q fever (occupational exposure from kangaroo …
55y · Female·acute necrotising bronchopneumonia
MQ, 55, died of acute necrotising bronchopneumonia on 2-3 March 2023. She had developed community-acquired pneumonia from 21 February 2023, presenting initially with referred shoulder pain (later recognised as diaphragma…
86y · Male·End-stage congestive cardiac failure on a background of dilated cardiomyopathy
Mark Lewis, aged 86, died from end-stage congestive cardiac failure in custody at Long Bay Hospital Aged Care Unit. He had multiple chronic conditions (dilated cardiomyopathy, chronic kidney disease, diabetes, ischemic h…
45y · Male·Diabetic ketoacidosis with multi-organ failure caused by pneumonia
A 45-year-old Aboriginal man with poorly managed diabetes and schizophrenia presented to Cowra District Hospital ED with lethargy, cough and fever. Despite being triaged as category 2 (urgent) with abnormal vital signs i…
60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…
James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…
3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…
Jade, a 3-year-old First Nations child, died from bilateral bronchopneumonia with neglect as a significant contributing factor. Her death was wholly preventable. The coroner identified critical failures: DCJ's Muswellbro…
77y · Male·Aspiration pneumonia complicating retropharyngeal plasmacytoma, cervical myelopa…
Philip Walker, 77, died of aspiration pneumonia complicating retropharyngeal plasmacytoma, cervical myelopathy, COPD and atrial fibrillation while in prison custody. He had complex medical needs including dysphagia from …
71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation …
A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxon…
Unknown·COVID-19 infection with various comorbidities as contributing factors
This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…
47y · Male·Sudden cardiac death in association with COVID-19 infection
Alen Imbrisak, a 47-year-old man incarcerated at Junee Correctional Centre, died on 26 January 2022 from sudden cardiac death in association with COVID-19 infection. He tested positive on 25 January 2022 during a centre-…
78y · Male·COVID-19 pneumonitis on a background of ANCA nephropathy, hypertension, and diab…
Denis Ives, a 78-year-old man with type 1 diabetes, chronic kidney disease stage 4, ANCA nephropathy and hypertension, died of COVID-19 pneumonitis while in custody at Long Bay Correctional Centre. He tested positive for…
44y · Male·cardiogenic shock, on a background of severe tricuspid valve regurgitation, seve…
Jeffrey Blundell, a 44-year-old man with severe intravenous drug use history, died from cardiogenic shock secondary to severe tricuspid valve regurgitation caused by infective endocarditis from non-sterile injection prac…
75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis
A 75-year-old woman with chronic pain and previous staphylococcal infections presented to Glen Innes District Hospital with a swollen, warm right knee 10 days after a corticosteroid injection. Junior doctor Dr M. appropr…
59y · Male·complications of viral liver cirrhosis with hepatocellular carcinoma
Mervyn Morgan, aged 59, died from complications of hepatocellular carcinoma arising from cirrhosis while in prison custody. Critical failures included: delayed monitoring of known liver cirrhosis (no ultrasound despite M…
20y · Male·cardiac arrest due to complications of infective endocarditis against a backgrou…
Maluovailoa Tafau, a 20-year-old man in custody, died from cardiac arrest due to infective endocarditis complicated by rheumatic heart disease. He had submitted two patient self-referral forms (September 2016 and Februar…
31y · Male·sepsis due to urosepsis and pneumonia on a background of C3 incomplete tetrapleg…
Michael Quinn, a 31-year-old quadriplegic inmate, died from sepsis secondary to urosepsis and pneumonia. He had C3 incomplete tetraplegia from a self-inflicted stab wound in 2013 and was serving a 20-year sentence. An in…
18y · Male·Multi organ failure due to sepsis from a Group A streptococcus infection
Alex Braes, an 18-year-old from Broken Hill NSW, died of multi-organ failure due to Group A streptococcus sepsis. He presented to Broken Hill Base Hospital three times over 24 hours with knee pain that progressed to seps…
74y · Male·Acute exacerbation of chronic airways disease, with carcinoma of prostate being …
William Berger, a 74-year-old man serving a life sentence for murder, died from acute exacerbation of chronic obstructive pulmonary disease (COPD) with metastatic prostate cancer as a significant contributing condition. …
28y · Male·MRSA sepsis
Mahmoud Allam, a 28-year-old man, died from MRSA sepsis whilst in custody at Parklea Correctional Centre. He initially presented with upper respiratory symptoms on 11 June 2016, followed by increasing symptoms including …
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