18 results
72y · Male·Complications of a gastroduodenal perforation (palliated) in the setting of mult…
William Anthony Daniel, a 72-year-old SDA resident with intellectual impairment and multiple comorbidities, presented to Box Hill Hospital on 7 November 2024 with postural hypotension, nausea, vomiting and abdominal pain…
57y · Male·Pneumonia with contributing factors of trisomy 21 and early Alzheimer's dementia
Graham Keith Moore, a 57-year-old man with Down syndrome and early Alzheimer's dementia, died of pneumonia at Bendigo Hospital on 11 February 2025. He resided in specialist disability accommodation and received NDIS-fund…
50y · Male·Sepsis of unknown organism in respiratory
Mark Ruth, a 50-year-old NDIS participant with cerebral palsy, intellectual disability, chronic dysphagia, and obstructive sleep apnoea, died from sepsis of unknown respiratory organism. He had experienced declining heal…
64y · Female·Complications of hospital acquired pneumonia and COVID-19 infection
Heather Maree Smith, a 64-year-old woman with severe cerebral palsy and multiple comorbidities residing in specialist disability accommodation, died from complications of hospital-acquired pneumonia and COVID-19 infectio…
46y · Female·Sepsis of unknown origin
Miranda Lynch, a 46-year-old woman with severe cerebral palsy, spastic quadriplegia, epilepsy, and aspiration pneumonia history, died from sepsis of unknown origin. She was admitted to Box Hill Hospital on 20 April 2023 …
75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis
A 75-year-old woman with chronic pain and previous staphylococcal infections presented to Glen Innes District Hospital with a swollen, warm right knee 10 days after a corticosteroid injection. Junior doctor Dr M. appropr…
60y · Male·sepsis and aspiration pneumonia in a man with oral squamous cell carcinoma and m…
Henry Allen, a 60-year-old man with oral squamous cell carcinoma, lung cancer, and multiple comorbidities died from sepsis and aspiration pneumonia while in prison custody at Fiona Stanley Hospital. He received appropria…
91y · Female·Complications of pelvic fractures sustained in a fall
A 91-year-old woman with osteoporosis and multiple comorbidities sustained pelvic fractures in a mechanical fall at home. She presented to the ED where initial hip x-ray showed no fracture. She deteriorated with hypotens…
76y · Female·pulmonary embolism due to carcinomatosis
A 76-year-old woman presented to hospital with shortness of breath and was initially diagnosed with community-acquired pneumonia and later pulmonary oedema. Both diagnoses were incorrect. She had widespread cancer (carci…
18y · Male·Incised wound to right axilla with complete transection of basilic vein, brachia…
Thomas Redman, aged 18, sustained a catastrophic laceration to his right axilla involving complete transection of major arteries and veins after putting his arm through a glass window at a rural property near Gloucester,…
80y · Female·Haemoperitoneum/retroperitoneal haematoma due to rupture of the abdominal aorta …
An 80-year-old woman presented to hospital after falls causing head injury and cervical spine fracture. Initial CT ruled out intracranial pathology. She developed undifferentiated shock at 5am, initially attributed to se…
35y · Female·Pulmonary thromboembolus and pulmonary infarction
A 35-year-old woman at 11 weeks gestation presented to Royal Women's Hospital Emergency Care on 3 September 2012 with chest and rib pain following severe vomiting. Dr M., a junior resident working alone overnight, assess…
71y · Female·Haemothorax and haemopericardium secondary to ruptured dissecting aneurysm of th…
A 71-year-old woman with hypertension and prior myocardial infarction presented to emergency with sudden chest pain, jaw pain, and syncope. Aortic dissection was appropriately suspected and a contrast CT-aortagram was pe…
71y · Female·aortic dissection (Stanford Type A)
A 71-year-old woman presented to hospital with pericardial effusion causing cardiac tamponade, successfully treated by pericardiocentesis. The underlying cause was a Stanford Type A aortic dissection, which was not ident…
48y · Female·Aspiration of stomach contents and pneumonia, following cardiac arrest
Margaret Webber, aged 48, with cerebral palsy and diabetes, died from aspiration of stomach contents and pneumonia. She presented to hospital with diabetic ketoacidosis (DKA) and coffee-ground vomit, which raised concern…
76y · Female·hospital acquired pneumonia, multiple organ dysfunction and small bowel obstruct…
Mrs Cook, a 76-year-old woman, died in January 2010 from hospital-acquired pneumonia, multiple organ dysfunction, and small bowel obstruction. She was admitted to a rural hospital with acute renal failure and dangerously…
85y · Male·Ruptured abdominal aortic aneurysm
An 85-year-old man with known inoperable abdominal aortic aneurysm died from rupture of this aneurysm while hospitalized for acute exacerbation of COPD. A medication error occurred at admission when Dr T. inadvertently i…
38y · Female·Streptococcus Group A Septicaemia (Post Partum-Puerperal Sepsis)
Susannah McLevie, a 38-year-old woman, died on 6 April 2006 from untreated Group A Streptococcal septicaemia (puerperal sepsis) following childbirth at Osborne Park Hospital. She developed fever (38°C) at 3am on 5 April,…
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