146 results
4y · Female·aspiration of vomitus and its treatment due to rheumatic carditis against a back…
A 4-year-old Aboriginal girl from Doomadgee died on 23 July 2009 from aspiration of vomitus complicating rheumatic carditis with concurrent viral respiratory tract infection. She presented with fever and cough on 19, 21,…
50y · Male·coronary artery disease in the setting of double vessel coronary atherosclerotic…
Brian Anderson, a 50-year-old quadriplegic resident of a disability support centre, died from coronary artery disease with double vessel disease and cardiomegaly. He had recently experienced a chest infection treated wit…
68y · Female·Anaphylactoid reaction to intravenous CT scan contrast medium leading to cardior…
A 68-year-old woman with asthma presented to hospital with abdominal pain suggestive of biliary obstruction. A CT scan with intravenous contrast was ordered to clarify the diagnosis before potential surgical transfer. Sh…
63y · Male·Metastatic carcinoma of the lung
Lawrence Jeffrey, a 63-year-old inmate at Lotus Glen Correctional Centre, died from metastatic lung carcinoma on 11 May 2008. He presented with symptoms consistent with his known chronic conditions (asthma, COPD, silicos…
20y · Female·food-induced anaphylaxis, likely to peanut allergen
Kylie Lynch, a 20-year-old woman with chronic asthma and a known peanut allergy, died from anaphylaxis on 2 September 2007 in Coral Bay, Western Australia. She consumed desserts at Fin's Café after dining at a nearby hot…
42y · Male·incised wound to the neck
Wesley Robert Jennings, a 42-year-old male with long-standing depression, anxiety, hepatitis C and substance use history, died by suicide by incised neck wound whilst on remand in prison. The coroner found no demonstrabl…
1y · Female·pneumonia (staphylococcal pneumonia with bilateral bacterial pneumonia)
Jezelle Lisa Gordon, a 1-year-old child, died of staphylococcal pneumonia on 26 February 2006 in Port Hedland, Western Australia. She presented to Halls Creek Hospital on 25 February with fever, elevated respiratory rate…
82y · Female·Hyperkalaemia due to acute renal failure on a background of end stage pulmonary …
An 82-year-old woman with terminal pulmonary fibrosis and chronic respiratory failure presented with chest pain, hyperkalaemia and metabolic acidosis. She became combative and was given haloperidol and morphine for agita…
65y · Female·gastrointestinal haemorrhage from duodenal ulcer
Margaret Bodell, 65-year-old with severe COAD and emphysema, was admitted with respiratory failure and developed a duodenal ulcer bleeding during hospitalisation. Critical clinical lessons include: (1) careful oxygen man…
44y · Male·Sepsis and pulmonary thromboemboli complicating a ruptured cerebral artery aneur…
Peter Gillam, age 44, died from sepsis and pulmonary thromboemboli complicating a ruptured cerebral aneurysm with subarachnoid haemorrhage (SAH). On 16 December 2004, his GP Dr H. referred him urgently for CT head to exc…
20y · Female·Cerebral anoxia consequent upon a severe acute asthmatic event
Sally Anne Gordon, a 20-year-old with a 14-year history of severe brittle asthma, presented to Mount Gambier Hospital on 26 November 2000 with acute severe asthma unresponsive to initial treatment. After appropriate emer…
16y · Female·consequences of acute asthma with hypoxic encephalopathy
Jessica-Lee Dennis, aged 16, died from acute asthma with hypoxic encephalopathy on 7 May 2004. She presented with progressive nocturnal cough and wheezing over six weeks starting September 2001, with significant family h…
63y · Male·complications from carcinoma of the lung
Lawrence John Hodson, a 63-year-old man detained in custody at Glenside Campus under the Criminal Law Consolidation Act, died from complications of lung cancer. He had been diagnosed with cancer in 2003 and was receiving…
81y · Female·aspiration pneumonia, exacerbation of chronic obstructive airways disease (emphy…
Patricia Nina George, an 81-year-old woman detained under mental health legislation at Glenside Campus, died from aspiration pneumonia, COPD exacerbation and congestive heart failure. A critical ambulance transfer delay …
46y · Male·Diffuse Alveolar Damage (Adult Respiratory Distress Syndrome) as a consequence o…
Anthony Kenneth Hansen, a 46-year-old inmate at Maryborough Correctional Centre, presented with flu-like symptoms on 24 August 2003 and was appropriately evaluated by visiting medical officers. Despite timely antibiotic …
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…
46y · Male·Upper airway obstruction due to acute tonsillitis with laryngeal oedema and haem…
A 46-year-old man with acute tonsillitis complicated by upper airway obstruction died at Cunderdin District Hospital. He presented with severe pharyngitis on 5 September 2002, was admitted to Kellerberrin Memorial Hospit…
25y · Male·cerebral craniopharyngioma
Gregory Andrew Furniss, a 25-year-old male with a history of asthma and congenital cataracts, presented to Swan District Hospital on 11 August 2002 with a persistent headache. He was seen by Dr H. (registrar) who diagnos…
41y · Male·haemorrhage due to incised wounds to left and right cubital fossae
Jeffrey Ronald Fredericks, aged 41, died in Adelaide Remand Centre custody from haemorrhage due to self-inflicted incised wounds to both cubital fossae. Critical clinical lessons: screening tools identified significant s…
60y · Female·haemorrhagic shock and respiratory failure due to right-sided haemothorax compli…
A 60-year-old woman with metastatic breast cancer and COAD died from haemorrhagic shock due to right-sided haemothorax complicating thoracentesis. The procedure was appropriately performed to drain a pleural effusion on …
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