21 results
43y · Female·Severe diffuse hypoxic brain injury caused by administration of supratherapeutic…
A 43-year-old woman died from severe diffuse hypoxic brain injury caused by excessive sodium bicarbonate administration during treatment of amitriptyline overdose. The treating ED consultant prescribed sodium bicarbonate…
67y · Female·Intra-abdominal sepsis complicating an anastomotic leak following elective surge…
A 67-year-old woman died from intra-abdominal sepsis following an anastomotic leak from elective colorectal surgery to repair a vesico-colic fistula. The initial surgery on 1 November 2017 was appropriately performed, an…
52y · Male·Polypharmacy overdose of amitriptyline and doxylamine in the context of underlyi…
A 52-year-old man with chronic facial pain, depression, obesity, cardiovascular disease and obstructive sleep apnoea died following restraint in ICU. He had ingested a polypharmacy overdose of amitriptyline and doxylamin…
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…
<1y · Female·Hypoxia resulting from primary idiopathic pulmonary hypertension of the newborn …
Jasmine Chiang died at 7 hours of age from primary idiopathic pulmonary hypertension of the newborn (PPHN), probably complicated by pulmonary haemorrhage. She presented with classic PPHN signs (harlequin appearance, diff…
43y · Male·Multi-organ failure with coagulopathy secondary to acute exacerbation of chronic…
A 43-year-old man with a colloid cyst of the third ventricle presenting with progressive headache was admitted for planned endoscopic surgery. Surgery was delayed from Friday to Monday due to unavailability of specialist…
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…
43y · Male·Coronary Atherosclerosis
Andrew Emerton, a 43-year-old prisoner with a history of substance abuse and psychiatric treatment, collapsed after vigorous exercise in custody. He called for help reporting shortness of breath and was found unconscious…
55y · Male·Morphine toxicity, with contributing factors of ischemic heart disease, coronary…
Shane Paul Krog, a 55-year-old man, died from morphine toxicity complicated by ischemic heart disease, coronary atherosclerosis and rhabdomyolysis. He presented to Murgon Hospital (a 15-bed rural facility) following susp…
<1y · Female·Perinatal asphyxia
Summer Elizabeth Rose Niehoff died from perinatal asphyxia hours after vaginal birth following a prolonged labour in hospital. The coroner found multiple clinically preventable failures: escalation of oxytocin augmentati…
52y · Female·Hypoxic brain injury due to hypotension in a woman with documented electrocardio…
Elizabeth Holley, 52 years old, was admitted involuntarily to a psychiatric ward with a history of three weeks of declining mental health and medication non-compliance. She received high-dose antipsychotic medications in…
34y · Male·self-inflicted hanging
Robert Gary Mitchell, age 34, died by self-inflicted hanging in cell 13 of Arthur Gorrie Correctional Centre on 9 July 2008. He was on remand without prior documented suicidal ideation or psychiatric history. Initial ris…
34y · Male·Air embolism and severe haemorrhage due to perforation of the right subclavian v…
Darryl Smith, aged 34, died following emergency surgery for a fractured clavicle at Sunnybank Private Hospital. During the final drilling of the sixth screw hole, the surgeon's drill penetrated the underlying right subcl…
16y · Female·Myocardial fibrosis (post myocarditic) resulting in fatal cardiac arrhythmia
Geordie Rose Duguid, 16 years old, collapsed and died at a private party after vomiting in a toilet. She had a history of glandular fever diagnosed late 2009. Post-mortem examination revealed myocardial fibrosis with wid…
<1y · Female·Hypoxic ischaemic encephalopathy due to true knot in umbilical cord
A term infant died from hypoxic ischaemic encephalopathy caused by a true knot in the umbilical cord. The mother presented in labour with spontaneous rupture of membranes and had a prolonged second stage. Foetal heart ra…
<1y · Male·Hypoxic Ischaemic Encephalopathy resulting from asphyxiation due to co-sleeping …
Nathaniel West, an 8-day-old Aboriginal newborn, died from hypoxic ischaemic encephalopathy following accidental asphyxiation due to co-sleeping (bed-sharing) with his mother at Kalgoorlie Regional Hospital on 4 May 2006…
39y · Male·Strychnine toxicity
Randall Coleman, 39, died from strychnine toxicity after deliberately ingesting poison while in custody at Kingaroy watchhouse on 18 January 2007. He had secreted the vial on his person at arrest on 16 January, despite p…
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…
Male·Hypoxic brain injury arising from intra-uterine asphyxia (causative factors unas…
William Keays was a neonate born at 37 weeks via emergency caesarean section for fetal distress during labour induction with Syntocinon. He was stillborn with Apgar scores of 0/0/1, requiring 12 minutes of resuscitation …
<1y · Male·cardiogenic shock and neonatal encephalopathy
Matthew Hutchinson, born at 1 day of age at Flinders Medical Centre, died from cardiogenic shock and neonatal encephalopathy. While obstetric care was appropriate, neonatal care was significantly deficient. Critical fail…
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