18 results
<1y · 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…
<1y · Male·Hypoxic ischaemic encephalopathy complicating peri partum asphyxia
A term neonate died at 3 days of age from hypoxic ischaemic encephalopathy due to perinatal asphyxia. The mother presented in early labour, was initially discharged, then readmitted when labour progressed. Labour progres…
<1y · Female·Disseminated Herpes Simplex Virus (HSV 1)
An 11-day-old neonate died from disseminated HSV-1 infection acquired perinatally. She presented with sepsis-like symptoms including lethargy, poor feeding, fever and respiratory signs. Clinical management was appropriat…
1y · Female·Gastrointestinal haemorrhage due to aorto-oesophageal fistula caused by lodged b…
Isabella Rees, aged 14 months, presented to Sunshine Hospital ED four times over 19 days with fever, vomiting and later haematochezia. A button battery lodged in her oesophagus caused progressive caustic injury leading t…
70y · Female·Tiger snake envenomation
Mrs Z, a 70-year-old woman, died from tiger snake envenomation after being bitten on the left foot while sleeping. She received two vials of antivenom within 2.5–4 hours of the bite at Royal Melbourne Hospital, consisten…
59y · Female·complications of intra-abdominal sepsis, including multi-organ failure and bowel…
59-year-old woman died from intra-abdominal sepsis, multi-organ failure and bowel perforation following median hepatectomy for cholangiocarcinoma. Key clinical issues included: surgical delays of 20 days between stent in…
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 …
19y · Female·Meningococcal septicaemia
Emma McGrath, a 19-year-old nursing student, died from meningococcal septicaemia caused by the W strain after presenting to the ED with a 12-hour history of vomiting, diarrhoea, abdominal pain and fever. The atypical pre…
<1y · 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…
29y · Female·Exsanguination post tubal ligation procedure
A 29-year-old woman died from exsanguination following an iatrogenic injury during elective laparoscopic tubal ligation at a regional hospital. A vascular injury to the right external iliac artery occurred during the pro…
77y · Female·Complications following a recent fracture and surgical repair of the right hip i…
A 77-year-old woman with complex comorbidities (atrial fibrillation, aortic stenosis, chronic renal impairment, emphysema) on Warfarin sustained a femur fracture and underwent ORIF on day 3 of admission (19 Nov 2009). Ke…
68y · Male·Dilated cardiomyopathy with previous aortic valve replacement and aortic graft
A 68-year-old man with aortic valve replacement died from undiagnosed dilated cardiomyopathy, with retroperitoneal haemorrhage as a contributing factor. He developed a large perinephric haematoma (1900mL) secondary to ov…
93y · Male·Intracranial haemorrhage in the setting of over-warfarinisation
A 93-year-old man on warfarin for atrial fibrillation sustained a head strike in a fall at residential aged care. Initial assessment by ambulance was appropriate and he was not transferred. Over subsequent days, neurolog…
<1y · Female·Subdural and subarachnoid haemorrhages due to late onset vitamin K deficiency bl…
A 33-day-old exclusively breastfed baby died from subdural and subarachnoid haemorrhages caused by late-onset vitamin K deficiency bleeding (VKDB). The parents, exercising informed choice based on spiritual beliefs, decl…
45y · Female·Extensive retroperitoneal haemorrhage following bone marrow biopsy procedure wit…
Susan Denise Evans, a 45-year-old woman with complex medical history including neurofibromatosis type 1, essential thrombocytosis, prior cancers, and recent cerebral infarcts on warfarin, underwent bone marrow biopsy at …
68y · Male·Internal haemorrhage due to coagulopathy and upper gastrointestinal varices, cir…
Robert Donald Rawson, a 68-year-old man with end-stage cirrhosis and multiple comorbidities, died hours after undergoing intercostal catheter insertion for pleural effusion drainage at Rockhampton Hospital. While the pro…
31y · Female·Post-partum Haemorrhage associated with Amniotic Fluid Embolism and Uterine Hypo…
Laura Marguerite Sinclair, 31-year-old primigravida, died from post-partum haemorrhage associated with amniotic fluid embolism (AFE) and uterine hypotonia. She underwent emergency caesarean section for foetal distress at…
63y · Male·pneumonia complicating anoxic brain injury, due to post-operative haemorrhage as…
A 63-year-old man died from pneumonia complicating anoxic brain injury following a post-operative haemorrhage from the inferior epigastric artery during ileostomy closure surgery. The critical failure was a 2.5-hour dela…
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