151 results
48y · Male·Pulmonary thromboembolism
Guy Christian Mason, 48, died from a saddle pulmonary embolism on 17 September 2023, three days after discharge from patellar tendon repair surgery. He had sustained a significant knee injury with multiple ligament ruptu…
61y · Male·bronchopneumonia complicating cerebrovascular accident due to cardioembolism on …
A 61-year-old man with a mechanical aortic valve underwent colonoscopy requiring temporary warfarin cessation. Following the procedure, he was discharged with a plan to recommence warfarin but without clear postoperative…
67y · Male·Multi-organ failure secondary to acute myocardial infarction secondary to in-ste…
Christopher Doughty, 67, was admitted to Hervey Bay Hospital on 17 September 2021 with a life-threatening gastrointestinal bleed two months after receiving coronary stents. The bleed was likely caused by dual antiplatele…
74y · Male·Acute myocardial infarction complicated by multiple organ failure
Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…
86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall
James Reilly, 86, fell at home on 8 September 2024 sustaining rib fractures that caused a fatal left haemothorax. Paramedics attended but he declined transfer. When facial droop developed, he was admitted with presumed t…
70y · Male·Metastatic melanoma with ischaemic heart disease as a contributing condition
Francis Michael Fahey, a 70-year-old prisoner, died from metastatic melanoma with contributing ischaemic heart disease. He presented with a rapidly enlarging axillary mass in February 2023, confirmed as metastatic melano…
61y · Male·Intracranial haemorrhage and myocardial infarct
A 61-year-old man with extensive cardiac disease collapsed at a supermarket, striking his head and losing consciousness for less than 10 seconds. Paramedics identified STEMI and administered heparin on advice from Austin…
58y · Male·Pulmonary thromboembolism complicating right calf deep venous thrombosis
Michael Burns, 58, presented to hospital with exertional chest pain and shortness of breath. He was diagnosed with stable angina and discharged home on cardiac medications. He returned the next day with dizziness attribu…
74y · Male·Incised wounds to limbs; other significant conditions being ischaemic heart dise…
Garry Reginald Dubois, a 74-year-old serving a life sentence for serious offences, died in custody from self-inflicted incised wounds to his limbs. He was on dual antiplatelet therapy for ischaemic heart disease, which c…
26y · Female·Pulmonary thromboembolism due to deep vein thrombosis (left leg) due to fracture…
A 26-year-old woman with a tibia fracture died from pulmonary embolism due to deep vein thrombosis. Despite multiple risk factors (obesity, oral contraceptive use, vaping, leg immobilization, prolonged immobility), no fo…
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…
64y · Male·acute myocardial infarction in association with coronary artery atherosclerosis
Leslie Charles Linton, a 64-year-old man with severe triple-vessel coronary artery disease, presented to Royal Perth Hospital on 15 December 2023 with an infected foot wound and acute psychosis. Initial troponin elevatio…
90y · Female·Right acute on chronic subdural haematoma sustained in a fall in the setting of …
A 90-year-old woman on warfarin for atrial fibrillation suffered an unwitnessed fall with head strike at an aged care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT …
75y · Male·Aspiration pneumonia in the setting of epilepsy and cerebral palsy
Raymond Charles Levy, a 75-year-old man with cerebral palsy and epilepsy living in supported disability accommodation, died from aspiration pneumonia. He presented to hospital with fatigue, fever and cough on 18 October …
70y · Male·intracranial haemorrhage secondary to haemorrhagic transformation of ischaemic s…
A 70-year-old man with chronic small vessel cerebral ischaemia died from intracranial haemorrhage following haemorrhagic transformation of an ischaemic stroke while in prison custody. He presented with acute stroke sympt…
57y · Female·Multi-organ failure due to drug-induced liver injury caused by sodium valproate …
Mrs Doherty, a 57-year-old woman with CADASIL syndrome, was prescribed sodium valproate for migraine prophylaxis in November 2019. She developed acute hepatitis approximately 5 months later, presenting with jaundice, nau…
57y · Female·starvation due to insufficient food intake
Patricia Iliev, a 57-year-old woman, died from starvation after progressively restricting her food intake over months while immobilised by chronic back pain. She had a gastrointestinal stromal tumour and advanced lung di…
60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…
James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…
53y · Male·Acute myocardial infarction due to triple vessel atherosclerosis and thrombosis …
A 53-year-old man with chest pain on exertion presented to his GP in March 2022. Initial investigations (blood tests, chest X-ray) were ordered but follow-up was delayed until July 2022. A cardiology referral was made, a…
86y · Female·Pulmonary thromboembolism in the setting of deep leg vein thrombosis, secondary …
Barbara Deal, 86, died from pulmonary embolism secondary to deep vein thrombosis 17 days after lumbar spinal fusion surgery. Critical failures included: no repeat VTE risk assessments despite policy requirements; inconsi…
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