246 results
84y · Female·allergic reaction to metoclopramide (Maxalon) in a woman with acute myocardial i…
An 84-year-old woman with acute myocardial infarction (AMI) and ischaemic bowel died following an allergic reaction to intramuscular metoclopramide (Maxalon) administered by nursing staff without a doctor's order, despit…
66y · Male·multiple organ failure associated with the combined effects of complications of …
Daniel Lahengking, a 66-year-old Indonesian visiting family in Esperance, was diagnosed with rheumatoid arthritis by locum GP Dr H. and prescribed methotrexate 5-10mg daily, a grossly excessive dose (normal: 7.5-20mg wee…
42y · Male·Cardiac arrhythmia secondary to electrolyte imbalance (hyperkalaemia) and verapa…
Glen Kingsun, 42, died from cardiac arrhythmia secondary to electrolyte imbalance and verapamil toxicity. He had complex medical needs requiring multiple specialist and GP care. Critical failures occurred: (1) Medication…
69y · Male·asphyxia by hanging
A 69-year-old man with depression, prostate cancer, and recent suicide attempt was admitted to MAPU (general medical ward) after intensive care treatment. He was deemed low suicide risk and the one-on-one attendant was d…
61y · Female·Peritonitis due to anastomotic leak at gastrectomy site; pathological obesity as…
A 61-year-old woman with pathological obesity died from peritonitis secondary to anastomotic leak following laparoscopic sleeve gastrectomy. The procedure itself was appropriate for her failed previous lap band surgeries…
70y · Female·Aspiration pneumonia, associated with Huntington's disease
Beryl Watson, a severely disabled 70-year-old with advanced Huntington's disease and dementia, died of aspiration pneumonia following a three-week respite stay at a BUPA aged care facility. Critical failures included: om…
84y · Female·Major cerebral infarct due to hypoglycaemia
Marie Goder, an 84-year-old with diabetes, developed severe hypoglycaemia following insulin administration at a nursing home on 1 November 2009, resulting in prolonged unconsciousness and bilateral cerebral infarcts. Aft…
69y · Male·Perforated bowel/septicaemia as a result of diverticulitis
A 69-year-old man presented to the ED with abdominal distension, incontinence and dehydration but was discharged with a diagnosis of depression and constipation. He returned 2 days later critically unwell and died of per…
73y · Female·pneumonia and renal failure with hyperthermia
Beryl Jean Morgan, 73-year-old aged care resident, died from pneumonia and renal failure with hyperthermia after a brief hospital admission. She had been prescribed haloperidol for behavioural problems; while neuroleptic…
Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…
Two obese patients died from hypoxic-ischaemic encephalopathy following cardio-respiratory deterioration post-operatively at a private hospital without overnight medical cover. John Ryan (54) deteriorated within hours of…
61y · Male·Pneumonia
Kenneth Morrison, a 61-year-old man with Down's syndrome, dementia and multiple comorbidities, died from pneumonia following hospitalisation at Casey Hospital in March 2008. Community Residential Unit (CRU) carers raised…
67y · Female·Lithium toxicity with chest infection and bipolar disorder; Alzheimer's disease …
Mrs Snopek, aged 67 with bipolar disorder on long-term lithium, was prescribed coversyl (an ACE inhibitor) by Dr A. in January 2008 for hypertension. This combination is contraindicated as ACE inhibitors impair renal fun…
60y · Female·Peritonitis due to anastomotic leak following subtotal colectomy for treatment o…
60-year-old woman died from septic shock due to anastomotic leak following subtotal colectomy for synchronous bowel cancers. Early postoperative bronchospasm complicated clinical assessment, leading focus on respiratory …
41y · Female·Intracerebral haemorrhage secondary to Posterior Reversible Encephalopathy Syndr…
Kerri Gunn, a 41-year-old woman five days post-caesarean delivery, presented to emergency with frontal headache, elevated blood pressure, proteinuria, abnormal liver function and lower limb oedema. She was admitted under…
51y · Male·congestive cardiac failure in association with ischaemic and hypertensive heart …
Tom Foski, a 51-year-old man with chronic schizophrenia, died from congestive cardiac failure associated with ischaemic and hypertensive heart disease. He had multiple medical comorbidities including diabetes, COPD, prev…
75y · Female·Abdominal infection following surgery (repair of recurrent umbilical hernia) - s…
Wilma Ray Jones, 75, died of abdominal infection and sepsis following uncomplicated umbilical hernia repair. Post-mortem revealed ischaemic bowel with infarction, likely caused by superior mesenteric artery occlusion tri…
77y · Female·Complications following a recent fracture and surgical repair of the right hip i…
A 77-year-old woman with complex comorbidities (atrial fibrillation, aortic stenosis, chronic renal impairment, emphysema) on Warfarin sustained a femur fracture and underwent ORIF on day 3 of admission (19 Nov 2009). Ke…
62y · Male·chronic congestive cardiac failure due to severe aortic valve stenosis and incom…
William Edward Hunt, aged 62, a life-sentenced prisoner, died from chronic congestive cardiac failure due to severe aortic valve stenosis and cardiomyopathy. His severe aortic stenosis was identified in 2003, but surgica…
55y · Male·Staphylococcal sepsis, complications of pressure sores and hypostatic pneumonia,…
Stephen Summers, a 55-year-old man with cerebral palsy and profound disability, died from Staphylococcal sepsis after rapid deterioration following deinstitutionalisation from Kew Cottages to community residential accomm…
19y · Male·Hanging
Meqdad Hussain, a 19-year-old Afghan asylum seeker, died by hanging in an immigration detention centre (Scherger IDC, Queensland) on 17 March 2011. He had a history of self-harm evident from scars on his forearms, noted …
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