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WA2024-07-10

Inquest into the Death of Kevin John KEATH

76y · Male·metastatic prostate cancer with terminal palliative care

Kevin John Keath, aged 76, died from metastatic prostate cancer while serving a life sentence at Casuarina Prison. He received holistic, compassionate, and appropriate healthcare throughout his incarceration, including r…

oncologypalliative caresystemdelay
WAhospital2023-07-25

Inquest into the Death of Frank Kenneth MAJOR

75y · Male·complications of metastatic prostate cancer and end-stage chronic obstructive pu…

Frank Kenneth Major, a 75-year-old prisoner with metastatic prostate cancer and end-stage COPD, died of natural causes in October 2021. The coroner found his overall medical care during incarceration was excellent and co…

palliative careoncologysystemenzalutamide
WAhospital2023-05-22

Inquest into the Death of Errol Warren BARTLETT

87y · Male·Metastatic carcinoma of the prostate with complications (end-of-life palliative …

Errol Warren Bartlett-Torr, aged 87, died of metastatic prostate cancer on 20 June 2021 whilst in prison custody and receiving palliative care at Bethesda Hospital. Clinical lessons include: (1) elevated PSA findings sho…

oncologypalliative carecommunicationsystemwarfarin
WAhospital2019-08-02

Inquest into the Death of Timothy James CHANDLER

52y · Male·multiple organ failure and pulmonary thromboemboli complicating generalised seps…

A 52-year-old man with longstanding refusal of medical care presented with severe cellulitis, sepsis, and previously undiagnosed heart failure secondary to sleep apnoea. He lacked capacity to consent to treatment due to …

emergency medicinegeneral medicine
WAhospital2017-03-31

Inquest into the Death of John HOUGHTON

72y · Male·Metastatic bladder cancer; likely mechanism pulmonary embolism from combined eff…

A 72-year-old male underwent hip replacement despite undiagnosed metastatic bladder cancer. Following referral from his GP in May 2014 for an ultrasound showing bladder wall irregularities suspicious for cancer, urologis…

urologyorthopaedic surgerydiagnosticdelaynitrofurantoin
WAhospital2017-03-31

Inquest into the Death of Anna Maria WINTER

94y · Female·Sepsis complicating management of vulval carcinoma in an elderly woman with seve…

A 94-year-old woman with vulval carcinoma underwent suprapubic catheter insertion at a private hospital on 14 May 2014. She appeared well post-procedure with normal observations. The following day, she was transferred by…

urologyoncologycommunicationsystem
WAhospital2015-08-28

Inquest into the Death of Constantinas PAPAKOSTAS

66y · Male·carcinomatosis complicated by recurrent sepsis and multisystem failure in a man …

A 66-year-old man with renal cell carcinoma died in hospital from carcinomatosis with sepsis and multisystem failure. Critical clinical lesson: haematuria in 2005 was not adequately investigated with imaging despite recu…

urologyoncologydiagnosticdelay
WAhospital2014-12-30

Inquest into the Death of Gheorghe Gruici

71y · Male·Organ failure in an elderly man receiving palliative medical care for renal fail…

Gheorghe Gruici, a 71-year-old life-sentenced prisoner, died of organ failure from chronic renal failure, infective endocarditis, and chest infection. Over 15 years in custody, he developed multiple comorbidities includi…

general medicinenephrologyomeprazole
WAhospital2004-06-17

Inquest into the Death of Edmiston

41y · Female·Peritonitis following surgical procedure to the urinary bladder, due to infected…

Cheryl Lee Edmiston, a healthy 41-year-old woman, died of peritonitis and sepsis following minor bladder procedures (cystoscopy, hydrodilatation, and biopsy) at Joondalup Health Campus on 14 February 2003. The biopsies w…

urologygeneral surgerydiagnosticmedicationamoxicillin

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