11 results
0y · Male·Complications following forceps delivery
A 3-day-old neonate died from complications of instrumental forceps delivery, specifically subgaleal haemorrhage with associated skull fracture and intracranial bleeding. Critical clinical lessons include: (1) complex fo…
2y · Male·Hyaline membrane disease and pneumonia in the setting of pneumothorax
A 2-day-old term infant (2670g, small-for-gestational-age) presented with respiratory distress at 11 hours of life. A capillary blood gas at 1:14pm showed mixed respiratory and metabolic acidosis indicating decompensatio…
0y · Unknown·unascertained
A 10-day-old neonate born at 36 weeks gestation presented to hospital with signs of sepsis including hypothermia, lethargy, poor feeding, and jaundice. Critical failures in recognition and triage occurred: the infant was…
61y · Male·Hypoxic encephalopathy arising from cardiac arrest following self-removal of a c…
Kelvin Moulds, a 61-year-old man, died of hypoxic encephalopathy following a cardiac arrest caused by self-removal of a central venous catheter (CVC) on day 14 post-bilateral lung transplant. The CVC was still in situ de…
Female·Sepsis in the setting of a lotus birth
A premature female neonate born at 36+5 weeks via emergency caesarean section developed sepsis and died at 2 days of age. She had been delivered with lotus birth (cord left attached to placenta) and vaginal seeding (mate…
12y · Male·Cardiac haemorrhage due to or as a consequence of congenital aortic stenosis (su…
Joshua Statis, a 12-year-old with complex congenital aortic stenosis, died 18 days after a redo Konno procedure and aortic valve replacement when a CardioCel patch to the right ventricular outflow tract (RVOT) ruptured, …
3y · Male·Influenza A infection (Type H3N2)
Aidan Mara, a 3-year-old boy with influenza A pneumonia and hyponatraemia, collapsed and died from cardiovascular failure on hospital day 3. Critical clinical lessons include: (1) distinguishing SIADH from dehydration ea…
1y · Female·Sepsis (Group A Streptococcus)
A nearly 16-month-old girl died from Group A Streptococcal sepsis after presenting to a regional private hospital emergency department. She had been seen multiple times by different GPs in the preceding weeks with viral …
0y · Female·Perinatal asphyxia
Baby XY, a 41-week-old newborn, died from perinatal asphyxia six hours after birth at Sunshine Hospital. The primary clinical lesson involves diagnostic failure: the mother was not diagnosed with gestational diabetes dur…
1y · Male·Staphylococcus aureus septicaemia of unknown origin
Leroy William Scott, a 15-month-old boy, presented to Geelong Hospital with fever, lethargy, and poor oral intake. He was triaged as semi-urgent and not seen by a doctor until 5 AM, 8 hours later. Blood cultures drawn at…
66y · Female·acute necrotising haemorrhagic mediastinitis
Mrs Pratt, aged 66, underwent elective gastroscopy at Kapunda Hospital. During the procedure she heaved, and blood was noted at the gastro-oesophageal junction. She was discharged the same afternoon with pain, only to re…
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