58 results
70y · Male·Acute myocardial infarction in association with coronary artery atherosclerosis
A 70-year-old sentenced prisoner with severe ischaemic heart disease and prior myocardial infarctions died from acute myocardial infarction with coronary artery atherosclerosis. He presented with severe chest pain on 5 O…
75y · Male·Multi-organ failure secondary to cardiogenic shock and anterior myocardial infar…
A 75-year-old man presented to a tertiary hospital ED with acute anterior STEMI but diagnosis was delayed by approximately 10 hours. The first hospital ECG at 6:47am showed diagnostic ST elevation but was not recognised …
86y · Male·Aspiration Pneumonia secondary to Recurrent Colorectal Carcinoma
An 86-year-old man died from aspiration pneumonia following bowel preparation for elective colonoscopy. He was admitted to an outlying ward rather than the gastroenterology unit, where nursing staff documented multiple e…
50y · Male·Multiple pulmonary thromboemboli due to deep vein thrombosis following pharyngea…
A 50-year-old man died from pulmonary thromboembolism following uvulopalatopharyngoplasty (UPPP) surgery for obstructive sleep apnoea. Critical failures in post-operative management at a private hospital included: failur…
87y · Male·Endobronchial and pulmonary haemorrhage secondary to pneumonia complicating chro…
An 87-year-old man with atrial fibrillation on warfarin underwent elective bronchoscopy for suspected lung lesion. The admitting respiratory team incorrectly documented a mechanical aortic valve replacement when he actua…
73y · Male·Acute intracranial haemorrhage, due to or as a consequence of coagulopathy, due …
Mr Stimpson, a 73-year-old man, died from massive intracerebral haemorrhage secondary to coagulopathy caused by inadvertent double administration of anticoagulants (Clexane and Xarelto). He developed bilateral pulmonary …
75y · Male·left retroperitoneal haemorrhage associated with lumbar spine surgery
A 75-year-old man with complex comorbidities including Parkinson's disease and cognitive impairment underwent two-stage lumbar spine surgery for degenerative disc disease with stenosis. Post-operatively, he developed a r…
55y · Female·Cardiac tamponade due to haemopericardium due to acute ruptured myocardial infar…
A 55-year-old woman with extensive coronary artery disease presented for elective stent placement to her left anterior descending artery. During the procedure, a small diagonal branch vessel was occluded—a recognised com…
62y · Male·Global cerebral ischaemia secondary to intra-operative hypotension following the…
A 62-year-old man died from global cerebral ischaemia following intra-operative hypotension after protamine administration during a cardiac ablation procedure. He had suffered a severe hypotensive reaction to protamine 8…
56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy
A 56-year-old woman presented to Knox Private Hospital with severe headache and eye symptoms on 16 June 2007. An ED physician diagnosed ischaemic stroke based on a subtle CT finding in the absence of focal neurological s…
72y · Male·Multiple organ failure due to sepsis caused by abdominal adhesions from previous…
Michael Hamilton, 72, presented with acute abdominal pain post-bladder surgery while anticoagulated with warfarin. Initial assessment suspected duodenal perforation based on CT findings; laparotomy was performed but foun…
62y · Female·acute subarachnoid haemorrhage following perforation of the anterior communicati…
Ann Margaret Sansom, a 62-year-old woman with Type 2 diabetes and cirrhosis, died from subarachnoid haemorrhage following perforation of the anterior communicating artery during an endovascular coiling procedure for a 3m…
32y · Male·Pulmonary embolism originating from deep vein thrombosis in right calf
A 32-year-old man died from pulmonary embolism six days after emergency appendectomy for perforated appendicitis. VTE prophylaxis was appropriately prescribed. However, the clinical team failed to investigate persistent …
Philip Byrne: pulmonary thromboembolism due to right calf deep vein thrombosis; …
Two patients died from pulmonary thromboembolism caused by undiagnosed deep vein thrombosis (DVT). Mr Byrne presented with right calf pain in February 2012; two GPs excluded DVT on clinical examination alone without orde…
63y · Male·Right cerebral infarction caused by infusion of medication via central venous li…
A 63-year-old man with COPD, liver cirrhosis and alcohol dependence underwent emergency hemicolectomy for caecal volvulus. Post-operatively he developed respiratory depression, hypernatremia and alcohol withdrawal requir…
81y · Male·Intracerebral haemorrhage in the setting of heparinisation for subclavian artery…
81-year-old Alan Webster with atrial fibrillation on long-term Warfarin underwent colonoscopy in August 2011. His anticoagulation was interrupted and bridging Clexane prescribed. Post-operatively, critically sub-optimal …
68y · Female·Haemorrhage secondary to right subclavian artery lacerations sustained during ce…
A 68-year-old woman died from massive blood loss following inadvertent puncture of the right subclavian artery during central venous line insertion. The anaesthetist used anatomical landmarks without ultrasound after an …
66y · Male·Intracerebral haemorrhage
A 66-year-old man with intracerebral haemorrhage and concurrent deep vein thrombosis died following an accidental tenfold heparin overdose. The patient received 20,000 units instead of 2,000 units due to a nurse misreadi…
47y · Male·Pulmonary thromboembolism in association with deep vein thrombosis
A 47-year-old man from Carnarvon underwent elective laparoscopic cholecystectomy at Geraldton Regional Hospital on 31 August 2009 after a 5-hour coach journey that morning. The VTE Risk Assessment Form correctly classifi…
43y · Male·Hypoxic brain injury secondary to haemopericardium and tamponade complicating ru…
Mr Trevor McDonald, 43-year-old male, died from hypoxic brain injury following cardiac tamponade complicating coronary angioplasty. During elective PCI at Frankston Hospital, he sustained right coronary artery perforatio…
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