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WAhospital2023-05-22

Inquest into the Death of Errol Warren BARTLETT

87y · Male·Metastatic carcinoma of the prostate with complications (end-of-life palliative …

Errol Warren Bartlett-Torr, aged 87, died of metastatic prostate cancer on 20 June 2021 whilst in prison custody and receiving palliative care at Bethesda Hospital. Clinical lessons include: (1) elevated PSA findings sho…

oncologypalliative carecommunicationsystemwarfarin
VIChospital2022-08-19

Finding into death of Ruth Ann McKenna

62y · Female·Hypovolaemic and cardiogenic shock (hysterectomy) in the context of cardiomegaly…

A 62-year-old woman with significant comorbidities (cirrhosis, cardiomegaly, thrombocytopenia, chronic kidney disease, COPD) died from hypovolaemic and cardiogenic shock during elective total laparoscopic hysterectomy fo…

gynaecologyanaesthesiadiagnosticsystemmetaraminol
NSWhospital2022-03-25

Inquest into the death of Anthony Barrett

54y · Male·Bowel ischaemia resulting from acute thrombosis of superior mesenteric artery an…

Anthony Barrett died from bowel ischaemia caused by acute thrombosis of his superior mesenteric artery and coeliac artery stents post-operatively. He had undergone left total knee replacement surgery at Fairfield Hospita…

orthopaedic surgeryvascular surgerycommunicationdiagnosticclopidogrel
NSWhospital2020-11-27

Inquest into the death of Makushla NIKOLAEVSKY

43y · Female·pulmonary embolism

A 43-year-old woman died from pulmonary embolism after hysteroscopy for investigation of heavy menstrual bleeding. Following the procedure, she developed left leg swelling on day 3. A Venous Doppler Ultrasound was perfor…

gynaecologyvascular surgerydiagnosticpossibly proceduralenoxaparin
NSWhospital2020-10-02

Inquest into the death of Madeline Newcombe

63y · Female·Pulmonary thromboembolism

A 63-year-old woman died from pulmonary thromboembolism within 24 hours of bilateral total knee arthroplasty despite aspirin and sequential compression devices. The surgeon assessed her as standard risk and did not presc…

orthopaedic surgeryanaesthesiacommunicationdiagnosticaspirin
NSWcommunity2020-01-24

Into the death of Thomas Redman

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,…

emergency medicinetrauma surgerycommunicationsystemoxygen
VIChospital2017-11-09

Finding into death of Emma Kate McGrath

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…

emergency medicineintensive careparacetamol
QLDhospital2016-02-29

Mr B - Non-inquest findings

84y · Male·Acute myocardial infarction precipitated by upper gastrointestinal haemorrhage f…

An 84-year-old man with multiple comorbidities was prescribed rivaroxaban for deep vein thrombosis despite being a practicing Jehovah's Witness who refused blood transfusions. Rivaroxaban cannot be monitored or reversed,…

cardiologyhaematologymedicationcommunicationrivaroxaban
WAPodcast2015-02-09

Inquest into the Death of Myosotis Julianna MORIARTY

68y · Female·acute gastrointestinal haemorrhage secondary to bilateral dental extraction

A 68-year-old woman on long-term warfarin therapy for a prosthetic aortic valve died from acute gastrointestinal haemorrhage following dental extraction. The dentist failed to obtain an INR test within 24 hours of the pr…

dentistrygeneral practicediagnosticcommunicationwarfarin

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