121 results
84y · Female·Myocardial infarction
Shirley McGuane, 84, died from myocardial infarction following elective proctocolectomy. Post-operative care was deficient: chest pain on day 2 post-op with ECG showing atrial fibrillation and new right bundle-branch blo…
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,…
84y · Female·acute left subdural haematoma
Marie Janet Ford, 84 years old with dementia, fell from a chair at a residential aged care facility and sustained an acute left subdural haematoma. She was on warfarin for deep vein thrombosis and atrial fibrillation. In…
51y · Female·Ischaemic heart disease
Pauline Margaret Dodd, 51, died of ischaemic heart disease at Sir Charles Gairdner Hospital on 4 March 2014. She was an involuntary psychiatric patient with long-standing bipolar affective disorder, complicated by childh…
69y · Female·Inadvertent intravenous administration of oral ciprofloxacin in the setting of a…
A 69-year-old woman with stroke, diabetes, atrial fibrillation and osteomyelitis died from inadvertent intravenous administration of crushed oral ciprofloxacin. The antibiotic was prescribed for the nasogastric tube but …
62y · Male·multiple co-morbidities including dementia, Parkinson's disease, undernourishmen…
Michael Nelson, 62, died at Westmead Hospital on 3 May 2014 with multiple comorbidities including early-onset dementia, Parkinson's disease, neck dystonia (torticollis), and undernourishment. He presented to ED with inab…
65y · Male·Multi-organ failure in a man with an ischaemic right leg treated with opioids
A 65-year-old man with multiple chronic conditions (COPD, cardiac failure, diabetes, obesity) was admitted with pneumonia and severe ischaemic right leg pain. Opioid analgesia for the leg pain precipitated delirium, requ…
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…
86y · Female·right subdural haematoma due to blunt head trauma with contributing excessive wa…
An 86-year-old woman died from subdural haematoma following a minor head injury, complicated by excessive warfarin anticoagulation. She was started on warfarin by a cardiologist on 19 December 2012 for atrial fibrillatio…
72y · Male·Multiple organ failure due to sepsis caused by abdominal adhesions from previous…
Michael Hamilton, 72, presented with acute abdominal pain post-bladder surgery while anticoagulated with warfarin. Initial assessment suspected duodenal perforation based on CT findings; laparotomy was performed but foun…
29y · Male·Multiple drug toxicity
Shane John Robinson, a 29-year-old prisoner with complex medical conditions including Crohn's disease, pulmonary embolism, anaemia and schizoaffective disorder, died from multiple drug toxicity in prison. He had been pre…
Unknown·Philip Byrne: pulmonary thromboembolism due to right calf deep vein thrombosis; …
Two patients died from pulmonary thromboembolism caused by undiagnosed deep vein thrombosis (DVT). Mr Byrne presented with right calf pain in February 2012; two GPs excluded DVT on clinical examination alone without orde…
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…
81y · Male·Intracerebral haemorrhage in the setting of heparinisation for subclavian artery…
81-year-old Alan Webster with atrial fibrillation on long-term Warfarin underwent colonoscopy in August 2011. His anticoagulation was interrupted and bridging Clexane prescribed. Post-operatively, critically sub-optimal …
80y · Female·peritonitis due to sigmoid resection margin leak following extended right hemico…
June Olive Pegg, 80, died from peritonitis following anastomotic leak after extended right hemicolectomy for colonic cancer. Critical delays in diagnosis occurred: a PET scan in May 2010 showed a colonic mass, but respir…
58y · Male·Amitriptyline toxicity
Lloyd Felman, a 58-year-old man with chronic pain, depression, and alcohol use, died from amitriptyline toxicity in July 2008. In the three weeks prior, he presented to hospital three times with bizarre high-risk behavio…
39y · Male·cardiac arrest caused by alcoholic cardiomyopathy
Ryan Smiler was a 39-year-old Aboriginal man who died from cardiac arrest caused by alcoholic cardiomyopathy while in custody at Darwin Correctional Centre. He had a long history of alcohol abuse, hypertension, and heart…
74y · Female·haemothorax secondary to dissecting thoracic aorta
Mrs Petzierides, a 74-year-old woman, presented to the emergency department with sudden-onset, severe left scapular pain radiating to the jaw, occurring shortly after midnight. She was assessed by an emergency medicine r…
80y · Male·gunshot wound to the head
An 80-year-old man with chronic back pain died by self-inflicted gunshot wound to the head on 1 March 2011. Five days before his death, he mentioned suicide using a rifle to his long-term general practitioner, Dr D., but…
73y · Male·Blunt head injury from fall, complicated by warfarin therapy
A 73-year-old man on warfarin therapy for atrial fibrillation died from traumatic head injury sustained in an unwitnessed fall from a ladder while pruning roses at his home. He had been admitted to intensive care but die…
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