22 results
59y · Male·Pneumonia in a man with cerebral palsy, asthma and epilepsy
Alfred Johann Faltermaier, a 59-year-old man with cerebral palsy, intellectual disability, asthma, and epilepsy, died from pneumonia with sepsis and multiorgan failure on 8 May 2025. Living in supported disability accomm…
64y · Male·Pneumonia secondary to ischaemic cerebrovascular incidents, hypertension, and at…
Yan Jin, a 64-year-old man with history of stroke, hypertension, and atrial fibrillation, was admitted to hospital after a witnessed fall from bed. Despite no fractures, he remained hospitalised for discharge planning gi…
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…
51y · Female·Aspiration pneumonia in a woman with cerebral palsy and epilepsy
Kathryne Callaghan, a 51-year-old woman with cerebral palsy, epilepsy and intellectual disability, died from aspiration pneumonia following COVID-19 infection. She was initially hospitalised in November 2022 with COVID-1…
46y · Male·sepsis following haemorrhoidectomy
46-year-old Justin Mark Dobson died from sepsis following a routine haemorrhoidectomy on 17 July 2019. He was discharged to the ward overnight but deteriorated significantly from 11:00 am on 18 July, showing hypotension,…
45y · Male·Global cerebral hypoxia following cardio-respiratory collapse due to anaphylaxis…
A 45-year-old man with poorly controlled diabetes, ischaemic heart disease, and recurrent lower limb infections died from anaphylaxis to intravenously administered flucloxacillin. He presented with sepsis secondary to a …
61y · Female·multi organ failure due to abdominal sepsis
Lesley Arndell, aged 61, died from multi-organ failure due to abdominal sepsis after undergoing a Whipple's procedure for pancreatic cancer. Key clinical lessons include: (1) patients with previous bariatric surgery requ…
51y · Male·Lobar pneumonia
Giuseppe Luci, a 51-year-old man with severe Fragile X syndrome, epilepsy and hearing impairment living in a DHHS group home, died from lobar pneumonia. On 29 October, he presented with vomiting and diarrhoea; a GP diagn…
80y · Male·Vasodilatory shock and multi-organ failure secondary to aspiration and cardiores…
George Kimpton, aged 80, died from vasodilatory shock and multi-organ failure secondary to aspiration pneumonia five hours after cardiopulmonary arrest in hospital following colorectal cancer surgery. He had developed a …
53y · Female·multiple organ failure as a result of septic shock
Pauline Kessell, aged 53, died from septic shock caused by overwhelming sepsis following endoscopic pyeloscopy with laser lithotripsy for a 5cm infected staghorn calculus on 12 August 2015. Critical clinical lessons: (1)…
18y · Female·Multiorgan failure complicating malnutrition in a female with liver cirrhosis, o…
An 18-year-old female with Down syndrome, autism spectrum disorder, and severe intellectual disability died from multiorgan failure complicating severe malnutrition, non-alcoholic fatty liver disease, and obesity. She pr…
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…
90y · Female·Hospital acquired pneumonia in the setting of recent fractures of neck of humeru…
A 90-year-old woman with multiple comorbidities residing in aged care sustained a hip fracture from a fall in January 2018. Following surgical repair and initial hospital treatment, she was transferred to a rehabilitatio…
70y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …
Ali Djawas, a 70-year-old Indonesian-born man with comorbidities (hypertension, diabetes, COPD), underwent elective right hemicolectomy on 13 March 2017 for a suspicious ileo-caecal lesion. Biopsies were benign, CT imagi…
77y · Male·sepsis due to retroperitoneal collection after biliary stent insertion on a back…
A 77-year-old Aboriginal man died from sepsis following a percutaneous transhepatic cholangiography (PTC) procedure that perforated his duodenum. Critical failures included: delayed diagnosis and treatment of peritonitis…
64y · Male·Septic shock secondary to urosepsis (Pseudomonas and Stenotropomonas maltophilia…
RD, a 64-year-old man with diabetes, amputation, and COPD, presented to a private hospital emergency department with suspected sepsis (vomiting, diarrhoea, hypotension, acute kidney injury, elevated troponin, hyperkalaem…
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…
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…
73y · Male·multisystem organ failure in the context of trauma and limb fracture
A 73-year-old Indigenous man with multiple comorbidities (diabetes, hypertension, obesity, sleep apnoea, ischaemic heart disease) sustained a right ankle fracture following collision with a motor vehicle while riding a m…
3y · Male·thrombotic microangiopathy
A 3-year-old child died from thrombotic microangiopathy (haemolytic uraemic syndrome) secondary to Shiga toxin-producing E. coli infection, likely acquired from consumption of unpasteurised milk. Early presentation to GP…
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