158 results
55y · Male·Unascertained natural causes
A 55-year-old man with chronic treatment-resistant schizophrenia died at Forensic Hospital while lawfully detained on 26 December 2024. He had presented to Prince of Wales Hospital on 17 December with chest pain, tachyca…
14y · Female·unascertained natural causes – possibly encephalitis leading to seizure or sudde…
SMS, a 14-year-old previously healthy girl, collapsed unexpectedly at home on 10 October 2021 and was found unresponsive and not breathing. Immediate resuscitation was commenced by family members and emergency services, …
37y · Male·Neck compression and the complications thereof
Simon Mackay, age 37, was admitted as an involuntary psychiatric patient on 12 July 2022 for acute methamphetamine-induced psychosis with paranoia and aggression, complicated by severe polysubstance dependence. Although …
29y · Male·Cardiac arrhythmia in the context of alcohol withdrawal and chronic alcohol misu…
A 29-year-old man died from cardiac arrhythmia in the context of severe alcohol withdrawal at a correctional facility. Initial assessment correctly identified moderate-to-severe withdrawal (AWS score 8) with seizure hist…
73y · Male·Thromboembolism on a background of a spindle cell tumour
Michael Anthony Guider, aged 73, was an inmate in NSW correctional custody when he developed progressive shortness of breath and lower limb swelling. He presented to Prince of Wales Hospital on 6 September 2024 and was f…
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…
42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…
Eve Brown, a 42-year-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ri…
23y · Male·Blunt force head injury
A 23-year-old man died from blunt force head injury after being struck during a violent altercation outside a Sydney hotel. He fell backwards, striking the back of his head on concrete and suffered multiple intracranial …
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 …
43y · Female·Subarachnoid haemorrhage due to a ruptured berry aneurysm
Trina McGrady, a 43-year-old Goomeroi woman, died from subarachnoid haemorrhage due to a ruptured berry aneurysm on 15 September 2020. She had been admitted to John Hunter Hospital following incidental discovery of two l…
32y · Female·Cardiac arrest due to hypoxia caused by dynamic hyperinflation arising from comp…
A 32-year-old woman with Sponastrime Dysplasia (a rare genetic bone disorder) died during elective bariatric surgery. She had undiagnosed subglottic stenosis (airway narrowing) and tracheobronchomalacia. Critical clinica…
1y · Unknown·unascertained
A 12-month-old infant suffered unexpected cardiac arrest at home nine days after receiving routine MMR, meningococcal, and pneumococcal vaccinations. He presented to Manning Base Hospital on 27 July 2020 with fever (38.5…
23y · Female·hypoxic ischemic encephalopathy and aspiration pneumonia as a result of hanging
BQ was a 23-year-old Aboriginal woman who died by hanging on the Paringa Ward at Cumberland Hospital while detained as an involuntary mental health patient. She had a complex psychiatric history with schizophrenia and bo…
<1y · Female·Unascertained
A 9-month-old girl died suddenly on 23 July 2018 following multiple head injuries from blunt force trauma sustained shortly before death. She had presented to medical practitioners multiple times in the preceding weeks w…
88y · Female·Complications of cholecystectomy surgery
Margaret Mariani, 88, died from complications of laparoscopic cholecystectomy for gallstone-induced pancreatitis. An iatrogenic small bowel perforation, likely caused by inadvertent suturing during closure, led to perito…
42y · Female·pneumonia with diffuse alveolar damage in the setting of mixed drug toxicity (Ba…
Allyson Bailey, a 42-year-old woman with complex polysubstance use disorder and borderline personality disorder, died from pneumonia with diffuse alveolar damage complicated by mixed drug toxicity (baclofen and pregabali…
28y · Male·Cardiac arrhythmia
Lathan Brown, a 28-year-old Aboriginal man, died of cardiac arrhythmia while in custody at Wellington Correctional Centre on 6 January 2024. He suffered sudden cardiac arrest in his cell; emergency response was appropria…
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…
62y · Male·cardiac arrhythmia secondary to prolongation of the QT interval
NL, a 62-year-old man with schizoaffective disorder and hypothyroidism, died of cardiac arrhythmia secondary to QT prolongation while an involuntary mental health inpatient. He had a known history of non-compliance with …
75y · Female·multiple organ failure due to severe anaemia secondary to blood loss post electi…
A 75-year-old woman died from multiple organ failure due to severe anaemia after elective hysterectomy surgery. Critical failures occurred: the surgical and anaesthetic teams held conflicting understandings about whether…
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