44 results
27y · Male·Sudden cardiac arrest in the context of physical and psychological exertion duri…
Steven Nixon-McKellar, a 27-year-old First Nations man, died following a physical altercation with Queensland Police officers attempting to arrest him on 7 October 2021. He suffered cardiac arrest during restraint, with …
78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…
78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). T…
79y · Female·Dilated cardiomyopathy with decompensated heart failure not appropriately treate…
A 79-year-old woman with severe COPD and heart failure presented with two weeks of nausea and vomiting. She was diagnosed with left ventricular failure (EF 33%) on day 1 of admission. Two cardiologists had key roles: Dr …
57y · Male·Metastatic lung adenocarcinoma (stage IVA non-small cell lung cancer)
Trevor Charles Stone, a 57-year-old First Nations man imprisoned for sexual offences, died from metastatic lung adenocarcinoma with contributing comorbidities (diabetes, hypertension, dyslipidaemia, ischaemic heart disea…
61y · Male·Multiorgan failure, due to, or as a consequence of metastatic lung cancer (suspi…
Shane Anthony May, a 61-year-old prisoner, died of multiorgan failure secondary to metastatic lung cancer after 44 days in custody. He presented with COVID-19 symptoms on reception, then developed progressive respiratory…
61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed
A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…
79y · Female·Chronic obstructive pulmonary disease
Jean Alice Dowson, 79, died in an aged care facility after being commenced on end-of-life medications. She had severe COPD and was frail (29kg). On 10 April 2017, when she deteriorated with respiratory distress, a Clinic…
81y · Male·Chronic lung disease (severe COPD) with atherosclerotic cardiovascular and valvu…
An 81-year-old man with severe COPD died following inappropriate interhospital transfer to a private hospital and subsequent management errors. Key clinical lessons: (1) patients with CO2 retention require explicit ident…
79y · Male·Pneumonia, due to or as a consequence of emphysema (chronic obstructive pulmonar…
Herbert Charles Hilsley, aged 79, died of pneumonia secondary to emphysema with contributing ischaemic heart disease while incarcerated at Rockhampton Base Hospital. He had extensive comorbidities including COPD, ischaem…
0y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…
A 10-month-old boy died following elective cleft palate repair surgery complicated by post-operative respiratory distress and subsequent cardiorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pu…
50y · Male·Gunshot wounds to the chest
Mark Sheppard, aged 50, died from gunshot wounds sustained during a police response to a hoax emergency call at a caravan park. He had terminal end-stage COPD with alpha-1 antitrypsin deficiency and was using home oxygen…
59y · Male·Carcinomatosis due to adenocarcinoma of the pancreas
Dennis Petzler, a 59-year-old prisoner, died from carcinomatosis due to adenocarcinoma of the pancreas with extensive metastatic spread. He presented with abdominal pain and nausea in June 2018, initially managed as gast…
86y · Male·Ischaemic heart disease on a background of valvular heart disease, prostatic enl…
An 86-year-old prisoner with multiple chronic illnesses (COPD, atrial fibrillation, emphysema) died of ischaemic heart disease in a palliative care unit. He was admitted to hospital on 21 April 2019 with end-stage COPD a…
58y · Male·Metastatic non-small cell lung carcinoma
Barry Haynes, a 58-year-old Aboriginal man, died of metastatic non-small cell lung carcinoma while on remand in custody. He had stage 4 lung cancer with brain metastases diagnosed in November 2016, shortly before his arr…
37y · Male·Cardiac failure due to sepsis due to bilateral bronchopneumonia
Matthew Russo, a 37-year-old man, died from sepsis and cardiac failure secondary to bilateral bronchopneumonia within 18 hours of consultation with Dr M.. The coroner found the medical treatment inadequate and inappropri…
27y · Male·Metastatic sarcoma
Brendon Lahrs, a 27-year-old prisoner, died from metastatic Ewing's sarcoma (CIC-DUX4 translocation type) in March 2017. He presented with a persistent cough in April 2016 and was initially managed with Ventolin for susp…
73y · Male·Lung cancer (squamous cell carcinoma)
Robert Skilton, aged 73, died of advanced squamous cell carcinoma of the lung while in prison custody. He had a 59-year smoking history and consistently declined medical care throughout 43 years of incarceration, with up…
85y · Male·respiratory failure due to chronic obstructive pulmonary disease
An 85-year-old man with COPD, diabetes, and peripheral vascular disease died from type 1 respiratory failure due to mucous plugging of airways. He presented with a foot ulcer and acute respiratory exacerbation, was admit…
76y · Male·Coronary atherosclerosis in the context of obesity, obstructive sleep apnoea, an…
A 76-year-old man with significant comorbidities including severe obstructive sleep apnoea, obesity, aortic stenosis, and ischaemic heart disease died from acute coronary atherosclerosis 36 hours after elective sacroilia…
87y · Male·Endobronchial and pulmonary haemorrhage secondary to pneumonia complicating chro…
An 87-year-old man with atrial fibrillation on warfarin underwent elective bronchoscopy for suspected lung lesion. The admitting respiratory team incorrectly documented a mechanical aortic valve replacement when he actua…
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