246 results
28y · Female·aspiration of gastric contents complicating laxative abuse
A 28-year-old woman died from aspiration of gastric contents complicating severe laxative abuse. She fabricated a terminal cancer diagnosis to conceal anorexia nervosa and factitious disorder. During a RAH admission, a C…
41y · Male·Cerebral hypoxia and bronchopneumonia; contributing factors: toxic megacolon, ce…
David Orton, a 41-year-old man with cerebral palsy, intellectual disability, and severe kyphoscoliosis, died from cerebral hypoxia and bronchopneumonia complicated by toxic megacolon and Salmonella infection. Over 18 mon…
61y · Male·exposure and dehydration, preceded by alcohol withdrawal and chronic alcoholism
A 61-year-old man with chronic alcoholism was admitted to hospital for alcohol withdrawal management. He became confused and paranoid on the ward, received appropriate medication, but left hospital unobserved approximate…
41y · Male·large volume thrombotic stroke within the distribution of the right posterior ce…
A 41-year-old man with acute posterior circulation stroke was misdiagnosed as encephalitis despite normal lumbar puncture findings. The critical failure was Dr R.'s failure to diagnose stroke on 7 September and arrange u…
52y · Male·Intracerebral haemorrhage
A 52-year-old man in remand custody at Port Phillip Prison was diagnosed with moderate hypertension in June 2015 and commenced on Ramipril. He experienced two periods of non-compliance with medication (July-August and Se…
69y · Male·septic shock due to infected decubitus ulcers complicated by osteomyelitis
A 69-year-old man with Parkinson's disease died from septic shock caused by infected pressure ulcers (stage 4 decubitus ulcers with osteomyelitis) that developed in aged care. Pressure sores appeared within 31 days of ad…
83y · Female·Hyponatraemic encephalopathy due to adverse effects of citaprolam and duloxetine…
An 83-year-old woman with pre-existing SIADH-related chronic hyponatraemia died from hyponatraemic encephalopathy following antidepressant therapy. Critical clinical lessons include: (1) the importance of accessing prior…
76y · Female·Acute renal failure due to dehydration due to upper gastrointestinal bleed
A 76-year-old woman with chronic pain was admitted to a small rural hospital on 1 April 2015 with haematemesis secondary to NSAID use. Blood tests were ordered on admission but not transported to the district hospital fo…
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 …
73y · Female·Multiple organ failure due to or as a consequence of sepsis due to or as a conse…
73-year-old woman died 12 days after elective colorectal surgery for synchronous caecal and rectal tumours. Post-operatively, she developed persistent low urine output and intermittent hypotension managed with repeated f…
68y · Female·Coronary heart disease
A 68-year-old woman with diabetes, hypertension, hypercholesterolaemia, COPD and chronic renal failure presented with chest pain and dyspnoea. She was admitted with suspected congestive cardiac failure; troponins were no…
46y · Female·Dilated cardiomyopathy (acute complication with sudden cardiac arrhythmia)
A 46-year-old woman with bipolar/schizoaffective disorder, poorly controlled type 2 diabetes, morbid obesity, severe obstructive sleep apnoea, and pulmonary hypertension died from acute dilated cardiomyopathy with sudden…
83y · Male·pneumonia and severe acute respiratory distress syndrome caused by Legionella ba…
An 83-year-old man died from pneumonia and respiratory distress caused by Legionella bacterium. He presented with abdominal symptoms and was initially misdiagnosed as having aspiration pneumonia rather than community-acq…
55y · Male·cardiac tamponade resulting from proximal aortic dissection due to hypertension
A 55-year-old man presenting with acute severe chest pain, headache and jaw pain to a regional hospital was evaluated for aortic dissection. A CT angiogram was performed but the radiologist's verbal report contained ambi…
84y · Male·aspiration pneumonia following rhabdomyolysis due to entrapment of his right arm…
David Cobham, aged 84 with dementia, died on 23 April 2015 from aspiration pneumonia following rhabdomyolysis caused by prolonged entrapment of his right arm in a bathroom hand rail at The Lodge aged care facility. His d…
36y · Male·Hanging
A 36-year-old male prisoner with complex psychiatric history, substance use disorder, and recent cancer diagnosis died by hanging in prison. Recent mental health assessments (within 3 days) had classified him as low suic…
33y · Male·Opiate toxicity
A 33-year-old man with previously unrecognized obstructive sleep apnoea was admitted with severe headache. The treating physician prescribed a complex regimen of escalating opiate doses including both slow-release (MS Co…
45y · Female·Combined effects of widely metastatic (end-stage) carcinoma of the cervix and br…
Teressa Maree Beswick, a 45-year-old woman with end-stage metastatic cervical cancer, died from the combined effects of her cancer and bronchopneumonia accelerated by a critical medication error. On 23 October 2014, she …
91y · Male·Multi-organ failure due to inanition complicating prolonged delirium of uncertai…
Gordon Charles Smith, 91, died from multi-organ failure due to severe malnutrition (inanition) complicating prolonged delirium of unknown cause at Repatriation General Hospital on 30 July 2014. He had been admitted volun…
51y · Female·Pulmonary thromboembolism in the setting of morbid obesity
Ms Quinlan, a 51-year-old woman with morbid obesity (BMI 74.2), depression, bipolar disorder and recent diabetes diagnosis, died from pulmonary thromboembolism while an involuntary psychiatric inpatient. She presented wi…
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