19 results
51y · Female·Methemoglobinemia in the context of lignocaine use
Danielle Cadan, 51, died from methemoglobinemia following a tooth extraction under lignocaine anaesthetic at a regional health service. The lignocaine was administered in normal therapeutic dose but triggered this rare l…
54y · Male·Hypoxic/ischaemic brain damage caused by blood loss and airway obstruction due t…
A 54-year-old male was assaulted in a nightclub with a single punch causing orbital and facial fractures and posterior epistaxis. He presented to the Royal Hobart Hospital ED with active bleeding. Critical deficits in hi…
20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…
Adam Fitzpatrick, a 20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged…
59y · Female·complications of abscesses following dental extraction, in a woman with cerebral…
Angela Cuthbert, a 59-year-old woman with severe cerebral palsy and dysphagia, died from complications of abscesses following extraction of all 14 teeth under general anaesthetic. Surgery occurred 20 June 2022; she devel…
71y · Male·Complications of metastatic squamous cell carcinoma (terminal palliation)
Leslie Shortte, a 71-year-old life prisoner, died from metastatic squamous cell carcinoma with complications. Critical failures in his prison medical care included: failure to complete annual health assessments after 201…
0y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…
A 10-month-old boy died following elective cleft palate repair surgery complicated by post-operative respiratory distress and subsequent cardiorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pu…
36y · Male·Cardiorespiratory arrest complicating propofol administration for endodontic pro…
Michael Anderson, a 36-year-old obese man (BMI 38.5), suffered cardiorespiratory arrest during a root canal procedure under conscious sedation with propofol administered by Dr S. in a dental office setting. He had undiag…
73y · Male·Disseminated malignancy (advanced lung carcinoma and mouth carcinoma) in a man w…
Robert Craig, aged 73, died from disseminated malignancy (advanced lung and mouth carcinoma) while in prison custody. He received suboptimal cancer treatment at Fiona Stanley Hospital due to communication failures betwee…
76y · Female·Ludwig's angina
A 76-year-old woman with Ludwig's angina presented to urgent care with facial swelling and fever. She was appropriately diagnosed and arrangements made for transfer to a tertiary centre. However, staff failed to recognis…
56y · Male·Pulmonary embolism with deep vein thrombosis an antecedent cause; coronary arter…
Peter Robin, a 56-year-old man with a medical history of hypercholesterolaemia, hypertension, obesity, and depression, underwent elective dental surgery on 28 October 2015 to remove four wisdom teeth and resect a cyst. H…
35y · Male·Hanging
Travis Lee Fernandez, aged 35, died by hanging in custody at Dhurringile Prison in November 2014. He had sustained bilateral mandibular fractures in January 2014 treated with open reduction and internal fixation (ORIF). …
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 · Male·Gunshot wound to the head
Raymond John Cox, an 84-year-old man with Alzheimer's disease, depression, and cognitive decline, died from a self-inflicted gunshot wound to the head. His wife had approached police in 2013 seeking assistance to remove …
68y · Female·acute gastrointestinal haemorrhage secondary to bilateral dental extraction
A 68-year-old woman on long-term warfarin therapy for a prosthetic aortic valve died from acute gastrointestinal haemorrhage following dental extraction. The dentist failed to obtain an INR test within 24 hours of the pr…
22y · Male·mixed drug toxicity due to methadone, codeine, and morphine (metabolite), compou…
William Wallrock, 22, died from mixed drug toxicity four days after wisdom tooth extraction. He was initially appropriately advised to use paracetamol and ibuprofen. When inadequate pain relief prompted him to seek furth…
21y · Male·cardiac arrest caused by acute bilateral pneumonia
Stephen Moon, a 21-year-old with autism and intellectual disability, died following wisdom tooth extraction complicated by ventilator-acquired pneumonia. Although discharged early from ICU after 3 days, he developed bila…
31y · Male·Upper airway obstruction due to pharyngeal abscess caused by dental abscess, whi…
Karl Scholz, 31-year-old male, died from upper airway obstruction due to pharyngeal abscess originating from untreated dental infection. He presented with severe facial cellulitis and abscess following dental procedures …
27y · Male·Airway obstruction due to sublingual and submandibular cellulitis (Ludwig's angi…
A 27-year-old man died from airway obstruction due to Ludwig's angina (bilateral sublingual and submandibular cellulitis) following a tooth extraction. Critical failures included: delayed treatment with inadequate timely…
39y · Male·Hypoxic brain injury due to respiratory obstruction following surgery for dental…
Richard Christopher Jankowski, a 39-year-old man, died from hypoxic brain injury due to respiratory obstruction following emergency surgery for a dental abscess with cellulitis. After initial treatment with antibiotics, …
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