99 results
49y · Female·Fatal Cardiac Arrhythmia
Melissa Stokes, 49, died from a fatal cardiac arrhythmia one day after successful abdominal hysterectomy and sling surgery. The coroner found the cause was not opioid-induced respiratory depression despite post-operative…
21y · Female·pulmonary embolism in association with deep vein thrombosis of the left leg
A 21-year-old woman died from pulmonary embolism associated with deep vein thrombosis following ankle fracture surgery and immobilisation. She was discharged without thromboprophylaxis despite multiple VTE risk factors (…
68y · Male·Pulmonary thromboembolus secondary to deep vein thrombosis
Ronald Wood, a 68-year-old with complex medical history including prior pulmonary emboli, was treated for rectal cancer requiring chemotherapy and major surgery. Warfarin anticoagulation was appropriately ceased due to b…
73y · Male·metastatic carcinoma of the lung with palliation
Norman Hazelgrove, a 73-year-old prisoner, died from metastatic lung carcinoma in September 2017. Early in his imprisonment (2013), a chest X-ray showed COPD but this diagnosis was not formally documented or managed desp…
65y · Male·ischaemic heart disease following complications of colorectal surgery
A 65-year-old man with significant comorbidities (cardiomyopathy, diabetes, obesity) underwent colorectal surgery for adenocarcinoma. Post-operative course was complicated by anastomotic breakdown causing sepsis on day 1…
50y · Male·Ischaemic and valvular heart disease (severe aortic stenosis) with other signifi…
A 50-year-old man with severe ischaemic and valvular heart disease (aortic stenosis) died suddenly in hospital following multiple myocardial infarctions. He had consistently refused invasive interventions including valve…
23y · Female·Arrhythmia of unknown aetiology
TV died on 1 November 2016 from arrhythmia of unknown aetiology whilst in MHICU at Prince of Wales Hospital. She was a 23-year-old with severe bipolar disorder, mild intellectual disability and borderline personality tra…
16y · Male·pulmonary embolism secondary to nephrotic syndrome
Dylan Riley, a 16-year-old with steroid-responsive minimal change nephrotic syndrome, died from a massive pulmonary embolism (PE) on 1 August 2015. He presented to Rockingham Hospital with dyspnoea, hypoxia, tachycardia …
47y · Male·Pulmonary thrombo-embolism secondary to deep vein thrombosis in setting of morbi…
A 47-year-old man with morbid obesity presented with respiratory failure, productive cough, and calf swelling. His GP appropriately suspected both pneumonia and pulmonary embolism (PE), requesting urgent CTPA. At Townsvi…
81y · Male·multi-organ failure complicating multiple right-sided rib fractures due to a fal…
An 81-year-old man sustained multiple rib fractures from a 1.5m ladder fall. Initial assessment at a rural hospital on day one was appropriate. However, when chest X-rays on day two revealed 9 rib fractures, the treating…
83y · Female·upper gastrointestinal bleed with haemodynamic compromise following anticoagulat…
Margaret Patricia Kenney, 83, died from upper gastrointestinal bleeding complicated by cardiac arrest while anticoagulated for atrial fibrillation. She had been diagnosed with gastro-oesophageal reflux disease (GORD) in …
59y · Male·pulmonary thromboemboli due to deep vein thrombosis following right hip replacem…
A 59-year-old man died from pulmonary thromboembolism following right hip replacement surgery. He had mild polycythaemia and elevated BMI (33.26), both risk factors for deep vein thrombosis. Pre-operatively he was classi…
72y · Male·hypovolemic shock due to haemoperitoneum following surgical repair of an abdomin…
A 72-year-old man died from hypovolemic shock due to intra-abdominal haemorrhage following Spigelian hernia repair. Post-operatively he presented with hypotension, bradycardia and sweating. ECG changes were misinterprete…
62y · Male·cerebral haemorrhage (intracerebral bleed, large lobar within left cerebral hemi…
A 62-year-old man presented to ED with dyspnoea, diaphoresis, and hypertension caused by an evolving cerebral haemorrhage. He was initially misdiagnosed with NSTEMI based on elevated troponin and atrial fibrillation, lea…
75y · Male·Right haemothorax complicating intercostal catheter insertion for the treatment …
Giuseppe Costa, 75, died from right haemothorax following intercostal catheter insertion for pleural effusion drainage. Critical failures in clinical management included: inadequate documentation of pleural fluid drainag…
67y · Male·respiratory failure with antecedent causes including chronic emphysematic lung d…
67-year-old male with 40-year smoking history presented with chest symptoms in 2012. CT scan revealed a left upper lobe mass. Core biopsy was incorrectly reported as adenocarcinoma by the pathologist, despite clinical un…
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…
41y · Male·Complications of blunt force injuries of the head
Colin Parker, aged 41, suffered an unwitnessed fall with head injury while experiencing syncope from atrial fibrillation in early May 2014. He was admitted to Campbelltown Hospital but his serious intracranial pathology …
31y · Male·Pulmonary thromboembolism
A 31-year-old man with obesity (BMI 40.2) and sleep apnoea underwent extensive cosmetic surgery in Malaysia (liposuction, abdominoplasty, chest lipectomy, and subsequent facial procedures) across two operations within fi…
57y · Male·large volume ischaemic infarct (stroke)
Stephen John French, a 57-year-old with prior stroke (2002) and myocardial infarction (2009), presented with headache, visual disturbance and gait difficulty in May 2013. Imaging at Launceston General Hospital on 30 May …
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