246 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…
61y · Male·Undetermined
Gerard Guy Vaz, a 61-year-old man with bipolar disorder, obstructive sleep apnoea, and renal impairment, was admitted to Maroondah Hospital on 2 April 2015 with acute manic relapse with psychosis. He was administered zuc…
60y · Female·Respiratory arrest in the setting of aspiration pneumonia; seizures associated w…
A 60-year-old woman with Down syndrome, Alzheimer's dementia, and epilepsy died from respiratory arrest due to aspiration pneumonia after a seizure. A multi-day delay in anticonvulsant medication (phenytoin) occurred due…
68y · Male·Pulmonary thromboembolus secondary to deep vein thrombosis
Ronald Wood, a 68-year-old with complex medical history including prior pulmonary emboli, was treated for rectal cancer requiring chemotherapy and major surgery. Warfarin anticoagulation was appropriately ceased due to b…
42y · Male·Aspiration pneumonia in the setting of impacted large bowel in a man with intell…
Chris Perdios, a 42-year-old man with intellectual disability, autism, and chronic constipation, died from aspiration pneumonia complicated by an impacted large bowel. He was admitted to hospital on 12 October 2018 with …
68y · Female·Sepsis (Enterobacter cloacae) due to peritonitis as a consequence of leaking per…
A 68-year-old woman with oculopharyngeal muscular dystrophy died from sepsis due to peritonitis following dislodgement of a PEG tube inserted on 27 February 2018. She presented to a rural hospital 5.5 hours post-discharg…
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…
45y · Male·Global cerebral hypoxia following cardio-respiratory collapse due to anaphylaxis…
A 45-year-old man with poorly controlled diabetes, ischaemic heart disease, and recurrent lower limb infections died from anaphylaxis to intravenously administered flucloxacillin. He presented with sepsis secondary to a …
85y · Female·sepsis, with aspiration pneumonitis being an antecedent cause. Iatrogenic injury…
Lorraine Barnes, an 85-year-old woman admitted to Wollongong Private Hospital for convalescence, died from sepsis with aspiration pneumonitis following iatrogenic lung injury. She developed severe malnutrition and electr…
89y · Female·Aspiration pneumonia complicating electroconvulsive therapy for treatment of psy…
Hilda Berg, 89-year-old woman with depression, psychosis, atrial fibrillation, chronic kidney disease and type 2 diabetes, deteriorated in hospital with refusal to eat or drink due to psychotic beliefs. After initial con…
18y · Female·Multiorgan failure complicating malnutrition in a female with liver cirrhosis, o…
An 18-year-old female with Down syndrome, autism spectrum disorder, and severe intellectual disability died from multiorgan failure complicating severe malnutrition, non-alcoholic fatty liver disease, and obesity. She pr…
47y · Male·Pulmonary thrombo-embolism secondary to deep vein thrombosis in setting of morbi…
A 47-year-old man with morbid obesity presented with respiratory failure, productive cough, and calf swelling. His GP appropriately suspected both pneumonia and pulmonary embolism (PE), requesting urgent CTPA. At Townsvi…
48y · Male·Septicaemia in a man with a psoas abscess; Diabetes mellitis
A 48-year-old man with insulin-dependent diabetes, mild cognitive impairment, and chronic alcoholic liver disease was admitted with sepsis from a psoas abscess. After 15 days of intravenous antibiotics, he refused IV con…
79y · Female·multi-organ failure as a result of ischaemic and valvular heart disease with uri…
Janet Ann Cook, aged 79, died of multi-organ failure complicated by hydromorphone toxicity on 30 September 2015. She was mistakenly administered 16mg hydromorphone intended for another patient (room 28 vs room 26) on 21 …
80y · Male·Bronchopneumonia complicating terminal palliative care in an elderly man with ch…
Aurelio Monterlegre Cruz, an 80-year-old man with complex medical conditions including chronic renal failure, ischaemic heart disease, diabetes, and COPD, died of bronchopneumonia complicating terminal palliative care wh…
31y · Female·urosepsis due to acute pyelonephritis
Catherine Joy Davis, a 31-year-old woman with severe lissencephaly, intellectual impairment, epilepsy and cerebral palsy, died from urosepsis due to acute pyelonephritis. She presented to ED with vomiting and constipatio…
83y · Female·upper gastrointestinal bleed with haemodynamic compromise following anticoagulat…
Margaret Patricia Kenney, 83, died from upper gastrointestinal bleeding complicated by cardiac arrest while anticoagulated for atrial fibrillation. She had been diagnosed with gastro-oesophageal reflux disease (GORD) in …
96y · Female·Pseudomonas aeruginosa sepsis secondary to infected leg ulcers, complicated by m…
A 96-year-old woman with diabetes, dementia and a chronic blistering skin condition developed progressively worsening leg ulcers with exposed tendons while resident in an aged care facility. Despite multiple medical revi…
75y · Male·Right haemothorax complicating intercostal catheter insertion for the treatment …
Giuseppe Costa, 75, died from right haemothorax following intercostal catheter insertion for pleural effusion drainage. Critical failures in clinical management included: inadequate documentation of pleural fluid drainag…
82y · Male·Cardiomegaly, myocardial fibrosis and ischaemic coronary artery disease in the c…
An 82-year-old man with extensive comorbidities underwent colonoscopy with argon plasma coagulation (APC) for bleeding angiodysplasia. Prolonged activation intervals during the final third of the procedure caused full-th…
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