99 results
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…
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 · 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 …
67y · Male·hypoxic respiratory failure in the setting of pneumonia, pulmonary embolism and …
Peter John Wallace, aged 67, died in custody at Lyell McEwin Hospital from hypoxic respiratory failure complicating pneumonia, pulmonary embolism, and advanced hepatocellular carcinoma. He had been imprisoned at Yatala L…
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…
74y · Male·Pulmonary thromboembolism in the setting of deep leg vein thrombosis
A 74-year-old man died from pulmonary thromboembolism with deep vein thrombosis 10 days after elective umbilical hernia repair. He received appropriate VTE prophylaxis (mechanical and pharmacological) intraoperatively an…
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…
59y · Male·Urosepsis and aspiration pneumonia (with Trisomy 21 as underlying condition)
Donald Raymond Muir, a 59-year-old man with Trisomy 21, non-verbal autism, dementia and epilepsy living in specialist disability accommodation, died of urosepsis and aspiration pneumonia. He had experienced progressive f…
48y · Female·intracerebral haemorrhage on a background of anticoagulation therapy for a recen…
Monique Jacinta Gomez, a 48-year-old woman with schizoaffective disorder and a mechanical aortic valve, died from intracerebral haemorrhage while receiving anticoagulation therapy for a recent embolic stroke. She was adm…
67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…
Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pa…
69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…
Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…
46y · Male·Aspiration pneumonia complicating epistaxis in the setting of prolonged nasal pr…
Hau Bui Nguyen, a 46-year-old man with severe acquired brain injury, dysphagia, and recurrent aspiration pneumonia, died from aspiration pneumonia complicating epistaxis following prolonged nasal prong oxygen therapy. Du…
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…
71y · Male·raised intracranial pressure caused by left frontal-temporal-parietal subdural h…
Warren James Newell, a 71-year-old man with oesophageal cancer, presented with acute coronary syndrome on 29 September 2022 and was appropriately diagnosed and treated with anticoagulation and dual antiplatelet therapy. …
76y · Male·pulmonary thromboembolism in the setting of deep vein thrombosis
A 76-year-old man with a history of unprovoked DVT/PE on lifelong warfarin was admitted with COVID-19 and developed a bleeding duodenal ulcer requiring endoscopic treatment. Warfarin was ceased to prevent further bleedin…
74y · Female·Cardiac arrest due to pulmonary embolism secondary to deep venous thrombosis
A 74-year-old woman presented to ED with left leg swelling and calf pain. She was triaged as category 4 and seen by a doctor after a 4-hour 24-minute delay due to staff shortages and access block. A D-Dimer test showed e…
68y · Female·Pulmonary embolism due to deep venous thrombosis secondary to fractured left dis…
Mary Morrow, aged 68, died from pulmonary embolism and deep vein thrombosis following a fractured left ankle sustained in Queensland on 23 June 2021. She received appropriate VTE prophylaxis initially (enoxaparin) but th…
29y · Male·Pulmonary thromboembolism secondary to deep venous thrombosis
A 29-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis (DVT) following a suicide attempt by hanging. He was admitted to ICU and appropriately commenced on prophylactic enoxaparin 40mg dai…
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