64 results
67y · Male·Complications of chronic obstructive pulmonary disease
A 67-year-old man with end-stage chronic obstructive pulmonary disease was serving a lengthy prison sentence in Corrective Services NSW custody at Long Bay Hospital's Aged Care and Rehabilitation Unit. In early October 2…
16y · Male·Anaphylaxis due to mammalian meat allergy after tick bite, causing an acute exac…
Jeremy Webb, 16, died from anaphylaxis due to mammalian meat allergy (tick-induced) which triggered status asthmaticus. He had experienced red meat reactions since age 10 and a severe respiratory event in April 2021 that…
51y · Male·combined effects of dilated cardiomyopathy with myocardial fibrosis and prescrip…
Jacob MacDonald, 51, died at the Forensic Hospital from combined effects of dilated cardiomyopathy with myocardial fibrosis and toxic levels of clozapine and aripiprazole. He was an involuntary forensic psychiatric patie…
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…
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…
83y · Male·Congestive cardiac failure due to ischaemic and valvular heart disease, with her…
Frank Valentine, an 83-year-old man, died from congestive cardiac failure due to ischaemic and valvular heart disease, with hereditary haemorrhagic telangiectasia (HHT) and anaemia as contributory conditions. He was serv…
65y · Male·Pneumonia, due to chronic lung disease with atherosclerotic cardiovascular disea…
A 65-year-old man with severe chronic lung disease, COPD, and coronary artery disease died at home. Evidence suggests he deliberately ingested benzodiazepines and possibly other substances in a self-harm attempt. However…
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 …
90y · Male·pneumonia complicating ischaemic heart disease
Francis William Athol Cable, aged 90, died in the Corrective Services NSW Secure Annex at Prince of Wales Hospital on 12 September 2022. He had complex medical comorbidities including ischaemic heart disease, chronic car…
46y · Male·Respiratory arrest secondary to acute exacerbation of bronchial asthma caused by…
A 46-year-old man with poorly controlled asthma and known ibuprofen hypersensitivity presented to a rural hospital with chest pain. A remote on-call doctor prescribed aspirin without knowledge of the allergy or availabil…
4y · Female·hypoxic brain injuries
A 4-month-old girl died from hypoxic brain injury following an unexplained, unnatural restriction of oxygen on 13 May 2017. She was found unresponsive at home and despite resuscitation, suffered irreversible brain damage…
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-…
48y · Male·Complications of infective exacerbation of bronchiectasis with cor pulmonale
A 48-year-old man with a significant history of bronchiectasis died in police custody from infective exacerbation of bronchiectasis with cor pulmonale. The inquest examined whether police took appropriate steps to obtain…
52y · Male·hanging
A 52-year-old man with a history of depression, ankylosing spondylitis, and severe obstructive sleep apnoea died by hanging in custody. He had requested a CPAP machine for over 9 months without receiving one, which he be…
64y · Male·Complications of eosinophilic asthma with bronchiectasis and allergic bronchopul…
Wayne Mullin, a 64-year-old man with severe eosinophilic asthma, bronchiectasis, and allergic bronchopulmonary aspergillosis, died between 21 September and 20 October 2021. Toxicology revealed oxycodone and diazepam at l…
54y · Male·metastatic small cell lung cancer
Manuel Katsaros, aged 54, died from metastatic small cell lung cancer while in custody at Prince of Wales Hospital Annex receiving palliative care. The coroner found no systemic deficiencies or clinical errors. The patie…
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…
70y · Male·ischaemic and valvular heart disease with chronic pulmonary disease being a sign…
Barry Faulkner, aged 70, died of ischaemic and valvular heart disease with chronic pulmonary disease while in lawful custody at Long Bay Correctional Complex on 25 January 2020. He suffered a sudden cardiac arrest while …
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