48 results
11y · Male·Bronchopneumonia and small bowel necrosis with perforation, in a boy with multic…
Child MML was an Aboriginal boy born in April 2010 who suffered catastrophic abusive head trauma at eight months old in December 2010, causing severe lifelong neurological impairment including cerebral palsy, uncontrolle…
47y · Male·unascertained
Eric Donald Brandrick, aged 47, disappeared from his home in North Fremantle, Western Australia, after 31 December 1989. He had suffered a severe stroke in September 1988 causing left-sided paralysis, visual impairment, …
48y · Female·intracerebral haemorrhage on a background of anticoagulation therapy for a recen…
Monique Gomez, 48, died from a spontaneous intracerebral haemorrhage during hospitalization for stroke rehabilitation and treatment of schizoaffective disorder. An initial ischaemic stroke resulted from non-compliance wi…
terminal palliative care in a girl with a clinical diagnosis of aspiration pneum…
A 12-year-old girl with severe cerebral palsy (quadriplegia) died from aspiration pneumonia whilst in state care following removal from her mother's care. Her mother, HC, had chronic benzodiazepine and opioid dependence,…
65y · Male·complications of intracranial haemorrhage (hypertensive haemorrhage), with termi…
Alan David Ratcliff, a 65-year-old prisoner at Acacia Prison, died from complications of intracranial haemorrhage (hypertensive haemorrhage) on 20 June 2022. He collapsed on 12 June 2022 with stroke symptoms and was hosp…
2y · Male·multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndro…
A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poo…
7y · Female·Pneumonia complicating a viral respiratory illness with acute combined drug effe…
Child ML, aged 7, died of pneumonia complicating viral respiratory illness with acute combined drug effect. She had severe cerebral palsy with complex care needs including PEJ tube feeding and multiple medications. At th…
89y · Male·Complications of cerebrovascular accident (stroke); specifically a catastrophic …
Hugh Ward, an 89-year-old sentenced prisoner, died from complications of stroke following an embolic cerebrovascular accident at Sir Charles Gairdner Hospital. While incarcerated, Mr Ward had multiple comorbidities inclu…
44y · Male·Unascertained; presumed exposure
Roly Nixon, a 44-year-old man with significant medical comorbidities including rheumatic heart disease, diabetes, organic psychosis and seizure disorder, disappeared from Fitzroy Crossing, Western Australia on 28 January…
3y · Male·Pneumonia and respiratory failure in association with metachromatic leukodystrop…
Child F, aged 3 years, died of pneumonia and respiratory failure complicating metachromatic leukodystrophy (MLD), a rare neurodegenerative genetic disorder. He had previously suffered severe non-accidental injuries inclu…
53y · Male·intracerebral haemorrhage
William Anderson, an Aboriginal man aged 53, suffered a catastrophic intracerebral haemorrhage while imprisoned and died despite timely emergency response. Multiple delays occurred: 25 minutes before the cell was opened,…
3y · Male·Hypoxic ischaemic encephalopathy complicating hypoglycaemia with shock and statu…
A 3-year-old boy with septo-optic dysplasia and panhypopituitarism died from hypoxic ischaemic encephalopathy secondary to adrenal crisis and hypoglycaemic shock. He was in state care and had an emergency management plan…
41y · Male·subarachnoid haemorrhage due to rupture of a berry aneurysm of the right interna…
A 41-year-old male prisoner died from subarachnoid haemorrhage caused by rupture of an undiagnosed berry aneurysm while incarcerated. He had a complex medical history including migraines, head injuries, hypertension, and…
3y · Female·bronchopneumonia in an infant with obstructive sleep apnoea
A 3-year-old Aboriginal girl died from bronchopneumonia complicated by severe obstructive sleep apnoea. She had rapid-onset childhood obesity (36 kg at death; normal weight 14-16 kg) with multiple cardiopulmonary complic…
3y · Female·tramadol toxicity
A 3-year-old girl in state care died from tramadol toxicity after accessing prescribed opioid medication left unsecured in her carer's bedroom. The child was removed from her mother's care due to neglect and substance ab…
5y · Female·aspiration of vomit with microscopic early pneumonia, in a child with a history …
A five-year-old girl with cerebral palsy and epilepsy resulting from non-accidental head injuries at two months old died from aspiration of vomit with early pneumonia. Critical lessons: bruising in non-ambulant infants i…
7y · Female·aspiration pneumonia leading to multi-organ failure in a female child with compl…
A child with severe cerebral palsy, hypoxic ischaemic encephalopathy, microcephaly and seizure disorder died of aspiration pneumonia leading to multi-organ failure. Born with severe perinatal brain injury, she had comple…
8y · Female·renal failure due to focal segmental glomerulosclerosis
A child with complex neurodevelopmental conditions (cerebral palsy/Rett Syndrome) and focal segmental glomerulosclerosis developed progressive renal failure and died at home on palliative care. The coroner found the medi…
7y · Male·cardiorespiratory failure in a child with cerebral palsy and epilepsy, with acut…
Child KT (Vinnie), age 7, died of cardiorespiratory failure from cerebral palsy and epilepsy after a prolonged hospital admission. He had complex medical needs including chronic respiratory disease, requiring PEG feeding…
13y · Male·Epileptic seizure with aspiration
Child L, a 13-year-old boy with autism, cognitive impairment and poorly controlled generalised epilepsy, died from sudden unexpected death in epilepsy (SUDEP) with aspiration. His seizures remained refractory despite app…
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