246 results
79y · Male·Acute Myocardial Infarction; Underlying multiple pathologies including vascular …
79-year-old man with complex medical history (ischaemic heart disease, pulmonary fibrosis, pacemaker, renal impairment, vascular dementia) died from acute myocardial infarction while in acute psychiatric care. He was tra…
47y · Male·Pulmonary thromboembolism in association with deep vein thrombosis
A 47-year-old man from Carnarvon underwent elective laparoscopic cholecystectomy at Geraldton Regional Hospital on 31 August 2009 after a 5-hour coach journey that morning. The VTE Risk Assessment Form correctly classifi…
58y · Male·Respiratory failure due to or as a consequence of Chronic Obstructive Pulmonary …
Geoffrey Hornby, a 58-year-old prisoner with significant COPD, ischemic heart disease, and multiple comorbidities, died from respiratory failure secondary to COPD. He was admitted to hospital with COPD exacerbation and d…
21y · Male·Acute hypoxic ischaemic encephalopathy and pneumonia in a man with recent trauma…
Peter Martin Carroll, age 21, died on 8 June 2007 in the ICU at Royal Perth Hospital from acute hypoxic ischaemic encephalopathy and pneumonia following oxycodone overdose. He had been discharged that day (5 June) after …
28y · Male·Gunshot wound to the head
Alen Deniro died by suicide on 5 May 2011 after learning of his de facto partner's death from terminal lung cancer. Psychiatrists appropriately assessed him as high suicide risk and initiated involuntary detention proced…
81y · Male·Acute myocardial infarction in association with coronary artery atherosclerosis
Robert Charles Bropho, an 81-year-old Aboriginal man imprisoned since 2008 with severe medical comorbidities including insulin-dependent diabetes, hypertension, chronic renal failure, and severe ischaemic heart disease, …
15y · Male·Cerebral ischaemia in a young man with a blocked ventricular peritoneal shunt an…
Vaughn Richard Rasmussen, a 15-year-old boy with congenital abnormalities and a ventricular-peritoneal (VP) shunt, died from cerebral ischaemia caused by acute blockage of his VP shunt on 17 November 2009. Between 12-16 …
17y · Female·Acute Lymphocytic Meningitis and Focal Myocarditis
Amy Lee Dawkins, 17, presented twice to Rockingham General Hospital ED within two weeks with severe headaches, myalgias, and vomiting. On 28 December 2008, she was discharged with a diagnosis of viral upper respiratory t…
63y · Female·bile peritonitis as a complication from a laparoscopic cholecystectomy
A 63-year-old woman died from bile peritonitis following laparoscopic cholecystectomy. The surgeon's intraoperative management was appropriate with no identified injuries. However, critical clinical deterioration on post…
31y · Male·Acute colonic pseudo-obstruction; death certificate amended to 'unascertained' -…
Cameron Yeates, a 31-year-old man with intellectual disability (IQ 64) and longstanding gastrointestinal issues, died from acute colonic pseudo-obstruction with underlying malnourishment. Key clinical lessons: (1) severe…
74y · Female·right lower lobe pneumonia (Staphylococcus aureus)
A 74-year-old woman admitted for depression and functional decline following aortic valve replacement received 15mg Nitrazepam instead of prescribed 15mg Mirtazapine due to drug name confusion. The sedation caused aspira…
62y · Male·multi organ failure due to atypical pneumonia
William Gripton, 62 years old with post-polio syndrome, presented to Kangaroo Island Hospital with upper respiratory tract infection that progressed to atypical pneumonia causing multi-organ failure and death. Critical c…
24y · Male·neck compression due to hanging
A 24-year-old man with depression and anxiety died by hanging in March 2009, three weeks after hospital discharge following an overdose. Critical clinical lessons emerge: (1) discharge summaries from psychiatric admissio…
37y · Male·combined ethanol and drug toxicity
Kenneth Agnew, a 37-year-old man resident in aged care, died from combined ethanol and drug toxicity involving methadone and benzodiazepines. He had hepatitis C and fatty liver disease. Critical clinical lessons include:…
51y · Female·Complications of anorexia nervosa
A 51-year-old woman with severe anorexia nervosa, BMI 12.1, was admitted to hospital acutely unwell with hypothermia, bradycardia, heart block, and extreme malnutrition. She was discharged after only 2 days with minimal …
0y · Female·perinatal pneumonia in association with meconium aspiration
Baby Sharinka Patricia Little, born prematurely at 35 weeks at Dalwallinu Hospital on 20 March 2008, died from perinatal pneumonia with meconium aspiration the same day. Critical clinical failures occurred during her nin…
63y · Female·Intra-cerebral bleed secondary to thrombocytopenia in a person with prolymphocyt…
Josephine Troy, 63, died on 14 February 2006 at Bunbury Regional Hospital from an intracerebral bleed secondary to thrombocytopenia (platelet count of 1) arising from prolymphocytic leukaemia. She had been in remission f…
85y · Female·Pulmonary embolus secondary to deep vein thrombosis, precipitated by minor fall
An 85-year-old woman died from pulmonary embolism secondary to deep vein thrombosis following a minor fall. She was admitted to Maryborough Hospital with chest infection and abdominal pain. Despite being identified as hi…
Male·Suicide: hanging (Al-Akabi, Saunders); diving from balcony (Rauluni)
Three immigration detainees died by suicide at Villawood Detention Centre in Sydney within three months in 2010. Josefa Rauluni (Fijian) jumped from a balcony on 20 September after being informed of imminent removal desp…
27y · Male·cardiac arrhythmia during restraint; mechanism involved hypoxia and asphyxiation…
Warwick Andrew Ashdown, a 27-year-old male with severe treatment-resistant paranoid schizophrenia, died at Graylands Hospital on 12 October 2007 from cardiac arrhythmia during physical restraint. After assaulting another…
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