98 results
85y · Female·Multisystem failure complicating ischaemic heart disease and ischaemic bowel in …
Lydia Maxfield, 85, died 5 days after elective left total knee replacement at a private hospital from multisystem failure due to ischaemic heart disease and ischaemic bowel. Critical clinical lessons: (1) Multiple abnorm…
55y · Male·head injury sustained in a single motorcycle crash
A 55-year-old man with multiple comorbidities (bipolar disorder, OCD, asthma, bronchiectasis, methadone dependency) died from head injury sustained in a motorcycle crash. He was riding 3 weeks after a previous motorcycle…
76y · Male·Bronchopneumonia in a man with ischaemic heart disease and treated spinal crush …
John Hayle, a 76-year-old with Alzheimer's dementia, ischaemic heart disease, and spinal fractures sustained a T11/12 flexion-distraction fracture on 9 June 2017. Over three weeks, he developed progressive bilateral lowe…
67y · Female·bronchopneumonia and acute liver failure on a background of liver cirrhosis and …
Valerie Kelly, a 67-year-old woman with cirrhosis, hepatocellular carcinoma, and multiple comorbidities, died at Royal Perth Hospital from bronchopneumonia and acute liver failure. She was in custody at Bandyup Women's P…
86y · Female·Sepsis complicating sacral decubitus ulceration in the setting of recent surgica…
Mrs Di Quinzio, an 86-year-old woman with multiple comorbidities, was discharged from hospital to a supported residential service (SRS) after hip fracture surgery. She required two-person assistance for mobility and was …
76y · Male·Hypothermia and multiorgan failure complicating compound left tibia and fibula f…
Leslie Roberts, a 76-year-old man with intellectual disability under DHHS care, died from hypothermia and multiorgan failure following a compound fracture of the left tibia and fibula sustained in a fall at home. He was …
24y · Male·Peritonitis secondary to a perforation of the small bowel
Nicholas Wells, a 24-year-old man, died from peritonitis secondary to small bowel perforation sustained in a motor vehicle accident. Although he was suspected of having a bowel injury at 11am on admission, he was placed …
60y · Female·Pulmonary thromboembolism in a woman recovering from a fractured right ankle
Maria Kerr, a 60-year-old woman with obesity and thalassemia minor, died from pulmonary thromboembolism 33 days after sustaining a fractured ankle. An administrative error resulted in her urgent orthopaedic follow-up app…
97y · Male·Complications of a fractured left neck of femur (operated), sustained in a fall
A 97-year-old man with vascular dementia, visual impairment, gait instability and multiple falls risk factors fell during a supervised outing from his aged care facility and sustained a fractured neck of femur. Despite b…
88y · Female·Sepsis complicated by multiple organ failure in a woman with comorbidities in th…
An 88-year-old woman died from sepsis with multiple organ failure following shoulder surgery. She developed an undiagnosed urinary tract infection after placement of an indwelling catheter. Critical failures included: in…
42y · Male·Cardiac arrest following hypoxic ischaemic encephalopathy, likely due to E.coli …
Jarrod Wright, a 42-year-old man admitted with cellulitis, developed sepsis-related acute respiratory distress syndrome (ARDS) requiring ICU care with non-invasive ventilation. Critical failures occurred in managing his …
22y · Female·septic shock complicating osteomyelitis secondary to cellulitis in a woman with …
Sarah Hammoud, aged 22 with cerebral palsy and intellectual disability, died from septic shock complicating osteomyelitis secondary to cellulitis. She resided in a supported residential service and had recurrent elbow in…
84y · Female·left lower lung bronchopneumonia in conjunction with small distal pulmonary embo…
An 84-year-old woman with comorbidities sustained right shoulder and pelvic fractures from an accidental fall. She presented to ED with low oxygen saturation (77%) requiring supplemental oxygen. Despite these injuries an…
73y · Male·Consequences of myocardial infarction with coronary artery atherosclerotic disea…
Leonard Bartholomeusz, aged 73, died of myocardial rupture on 6 May 2013, six days after hip fracture surgery. He suffered a fall on 30 April 2013 following which ECG testing revealed cardiac abnormality. A first ECG at …
54y · Male·aspiration pneumonia caused by multiple drug toxicity
Paul Lau, aged 54, died from aspiration pneumonia caused by opioid toxicity following ACL reconstruction surgery. The death resulted from a prescribing error where anaesthetist Dr K. inadvertently prescribed a 100mcg/hou…
76y · Male·Coronary atherosclerosis in the context of obesity, obstructive sleep apnoea, an…
A 76-year-old man with significant comorbidities including severe obstructive sleep apnoea, obesity, aortic stenosis, and ischaemic heart disease died from acute coronary atherosclerosis 36 hours after elective sacroilia…
73y · Male·Acute intracranial haemorrhage, due to or as a consequence of coagulopathy, due …
Mr Stimpson, a 73-year-old man, died from massive intracerebral haemorrhage secondary to coagulopathy caused by inadvertent double administration of anticoagulants (Clexane and Xarelto). He developed bilateral pulmonary …
50y · Female·Potentially fatal multiple drug toxicity (oxycodone, mirtazapine, citalopram, cl…
Ms RF, a 50-year-old woman with epilepsy and chronic pain from a workplace wrist injury, died from potentially fatal multiple drug toxicity involving oxycodone, mirtazapine, citalopram, clonazepam, and pregabalin. She en…
43y · Female·acute multiple drug toxicity on a background of chronic pain and morbid obesity
A 43-year-old woman died from acute multiple drug toxicity after 26 years of high-dose opioid therapy for chronic pain following a motor vehicle accident. Despite recognition by multiple clinicians that opioid doses exce…
67y · Male·ischaemic heart disease
A 67-year-old man with ischaemic heart disease and paroxysmal atrial fibrillation underwent arthrotomy for septic arthritis of the knee. He developed post-operative delirium attributed to anaesthesia, analgesics (tramado…
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