146 results
10y · Male·complications of anaphylaxis
Ronak Satyajit Warty, a 10-year-old boy with known milk and nut allergies, died from anaphylaxis after ingesting a coconut drink that was mislabelled and contained undeclared dairy products. Despite his parents' diligenc…
15y · Male·Global ischaemic brain injury post cardiac arrest secondary to anaphylaxis
Jack Glen Irvine, a 15-year-old with documented severe nut allergies and asthma, died from anaphylaxis triggered by consuming a macadamia nut cookie at a Victorian Karting Association camp. The cookie was provided despit…
49y · Female·Unascertained (natural)
Miriam Ralph, a 49-year-old woman with intellectual disability, bipolar disorder, Parkinson's disease, and asthma, died at a disability services facility following a choking episode and acute respiratory distress. She ha…
50y · Male·acute myocardial infarction due to coronary atherosclerosis
Allen Burke, a 50-year-old Aboriginal man in custody, died from acute myocardial infarction due to severe coronary atherosclerosis. On the morning of his death, he reported headache, vomiting, and sore throat. Nurse asse…
73y · Male·Combined effects of ischaemic heart disease and chronic obstructive pulmonary di…
A 73-year-old man in prison custody died from combined ischaemic heart disease and chronic obstructive pulmonary disease. He had a significant cardiac history including aortic repair and endocarditis, plus severe COPD wi…
77y · Male·Complications of reaction to an iron infusion in a man with ischaemic heart dise…
A 77-year-old man with iron deficiency anaemia and underlying ischaemic heart disease died from anaphylaxis following iron polymaltose infusion. Critical clinical lessons: (1) IV iron should only be administered after or…
18y · Male·Aspiration pneumonia in a setting of acquired brain injury from non-accidental h…
Jay Dion Sykes, aged 18, died from aspiration pneumonia in the setting of acquired brain injury sustained non-accidentally as an infant. He had severe cerebral palsy, tetraparesis, aphasia, visual impairment, intellectua…
87y · Female·acute intracranial haemorrhage
An 87-year-old woman with dementia, hypertension, and DVT died from acute intracranial haemorrhage while an inpatient at a general hospital under a Mental Health Act detention order. She was on warfarin for DVT managemen…
91y · Male·Severe heart failure secondary to ischaemic cardiomyopathy
Ernest Robert Tester, a 91-year-old man with ischaemic cardiomyopathy and severe heart failure, died in an aged care facility. He experienced chest tightness and difficulty breathing at 2am, treated appropriately by nurs…
81y · Male·Aspiration pneumonia complicating end stage fronto-temporal dementia on a backgr…
Murray Lawrence Abinett, aged 81, died of aspiration pneumonia complicating end-stage fronto-temporal dementia with chronic obstructive lung disease, ischaemic heart disease and chronic renal failure. He was detained und…
48y · Male·Ischaemic Heart Disease
Victor John Russell, aged 48, died in prison of ischaemic heart disease (90-95% left anterior descending coronary artery narrowing). He had family history of early cardiac disease, prior borderline QTc prolongation on EC…
55y · Male·Complications of fibrosing alveolitis
John Majinski, a 55-year-old prisoner with severe fibrosing alveolitis, pulmonary hypertension, diabetes, and recurrent infections, died from complications of his lung disease while incarcerated. He received intensive me…
9y · Male·asthma - acute episode of asthma which became increasingly resistant to Ventolin
Hunter Campbell Marr, a 9-year-old with episodic asthma, was admitted on 2 January 2014 with asthma exacerbation. His parents denied or minimised his asthma diagnosis despite previous PICU admission in 2011. During the J…
1y · Male·Staphylococcus aureus septicaemia of unknown origin
Leroy William Scott, a 15-month-old boy, presented to Geelong Hospital with fever, lethargy, and poor oral intake. He was triaged as semi-urgent and not seen by a doctor until 5 AM, 8 hours later. Blood cultures drawn at…
84y · Female·allergic reaction to metoclopramide (Maxalon) in a woman with acute myocardial i…
An 84-year-old woman with acute myocardial infarction (AMI) and ischaemic bowel died following an allergic reaction to intramuscular metoclopramide (Maxalon) administered by nursing staff without a doctor's order, despit…
61y · Female·Peritonitis due to anastomotic leak at gastrectomy site; pathological obesity as…
A 61-year-old woman with pathological obesity died from peritonitis secondary to anastomotic leak following laparoscopic sleeve gastrectomy. The procedure itself was appropriate for her failed previous lap band surgeries…
57y · Female·Aspiration pneumonia in a woman with cerebral palsy
A 57-year-old woman with severe cerebral palsy, intellectual disability, epilepsy, and a history of aspiration pneumonia died from aspiration pneumonia. She presented to hospital with upper respiratory symptoms initially…
Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…
Two obese patients died from hypoxic-ischaemic encephalopathy following cardio-respiratory deterioration post-operatively at a private hospital without overnight medical cover. John Ryan (54) deteriorated within hours of…
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…
65y · Female·Aspiration pneumonia with Down syndrome as underlying condition
Bernadette Rogers, a 65-year-old woman with Down syndrome and intellectual disability, died from aspiration pneumonia with severe oropharyngeal dysphagia as a contributing factor. She had suffered recurrent chest infecti…
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