2,781 results
78y · Female·Multiple organ failure secondary to sepsis and renal failure due to bronchopneum…
A 78-year-old woman with cognitive impairment, depression, and complex care needs fell at home on 11 February 2022. Her sons delayed seeking medical help for 4 days, during which she developed aspiration pneumonia and wa…
64y · Female·Presumed massive pulmonary embolus
Mrs Keating, aged 64, presented to University Hospital Geelong ED with a two-day history of shortness of breath and cough, with known history of pulmonary embolism. Attending physicians appropriately considered PE as dif…
74y · Male·Pulmonary thromboembolism due to right deep vein thrombosis
Richard Holden, aged 74, presented to his GP Dr C. multiple times in August 2020 with progressive shortness of breath and wheeziness. Dr C. diagnosed and treated asthma despite worsening symptoms and failure to respond t…
48y · Male·Pulmonary thromboembolism
Guy Christian Mason, 48, died from a saddle pulmonary embolism on 17 September 2023, three days after discharge from patellar tendon repair surgery. He had sustained a significant knee injury with multiple ligament ruptu…
62y · Male·multi-organ failure on a background of aortic regurgitation and ischaemic heart …
A 62-year-old man with aortic regurgitation and coronary artery disease died from multi-organ failure after emergency cardiothoracic surgery. His elective surgery was cancelled twice (14 and 22 Aug 2023) due to prioritiz…
32y · Female·cerebral venous sinus thrombosis complicated by right intracerebral haemorrhage
Kate Sylvia, 32, presented on 2 December 2021 with severe headache, vomiting, and neurological symptoms including slurred speech. Paramedics transported her to Sefton Park intermediate care instead of hospital. Dr H. mis…
23y · Male·complications of bowel obstruction by adhesions
A 23-year-old man in lawful custody at Parklea Correctional Centre presented on 7 January 2022 with severe chest pain, abdominal pain, vomiting, and dehydration, with a significant history of previous abdominal surgery a…
70y · Male·metastatic gastric adenocarcinoma
A 70-year-old man with prior bladder cancer was undergoing routine CT surveillance. Stomach cancer signs were clearly visible on February 2017 and February 2018 CT scans but failed to be detected by consulting radiologis…
40y · Male·Carbon monoxide toxicity
Paul Shen Vun Wong, a 40-year-old man with treatment-resistant schizophrenia and schizoaffective disorder, died from carbon monoxide toxicity at his Rockingham home in April 2023 while subject to a Community Treatment Or…
Male·toxicity caused by a combination of methylamphetamine and morphine
Felipe Esteban Alvarez died on 30 March 2021 from toxicity caused by methylamphetamine and morphine (heroin) ingestion at his unit in Taylor, ACT. He collapsed after self-injecting heroin in the presence of others, inclu…
Male·unascertained
KM, an adult with mental health conditions (anxiety, depression), opioid dependence, and hepatitis C, presented to Alfred Hospital ED on 20 December 2024 with bilateral lower leg cellulitis. After initial IV antibiotics,…
94y · Female·Drug toxicity (baclofen, gabapentin, oxycodone, pregabalin, zolpidem)
A 94-year-old residential aged-care resident died from drug toxicity after receiving another resident's medications. An agency nurse, unfamiliar with the patient and interrupted during medication preparation, failed to p…
69y · Female·Exacerbation of chronic obstructive pulmonary disease and ischaemic heart diseas…
Lynette McHarry, aged 69, died on 15 August 2024 at Casey Hospital following complications from a preventable medication error at Mooraleigh Hostel residential aged care facility. On 4 August, she was mistakenly administ…
31y · Male·Unascertained natural causes
Muhammad Ali Abdou, a 31-year-old roof plumber, died suddenly on 4 January 2023 while working alone on an elevated boom lift at a construction worksite in Truganina, Victoria. He was installing roof gutters at approximat…
62y · Male·complications of chronic alcohol misuse and olanzapine toxicity
John Aramathuparambil John, a 62-year-old with chronic alcohol dependence and depression, was arrested for trespass following a confused intrusion into a home on 6 June 2023. Police noted confusion and apparent intoxicat…
21y · Male·Cerebral temporal lobe uncal and cerebellar tonsillar herniation
Brady Hubbard, 21, died from traumatic brain injury with cerebral herniation after falling from an unsecured utility vehicle driven by Andrew Hilfenhaus at West Ulverstone Football Club in June 2023. While riding on the …
61y · Male·bronchopneumonia complicating cerebrovascular accident due to cardioembolism on …
A 61-year-old man with a mechanical aortic valve underwent colonoscopy requiring temporary warfarin cessation. Following the procedure, he was discharged with a plan to recommence warfarin but without clear postoperative…
34y · Male·Hanging
BS, a 34-year-old man with PTSD and depression from previous custodial assault, was remanded on drug importation charges at MRRC during COVID-19 restrictions. Critical clinical failures included: (1) 118-day delay in psy…
64y · Male·ischaemic and hypertensive heart disease (operated) with cardiomegaly with contr…
A 64-year-old man with ischaemic heart disease, cardiomegaly, diabetes and obesity died at home from cardiac failure after calling his care worker for assistance. A paramedic arrived but refused to force entry, instead a…
61y · Male·Exsanguination from sharp force injuries to both arms, dissecting the veins of t…
CG, aged 61, died in Parklea Correctional Centre on 18 May 2024 from hemorrhage due to self-inflicted sharp force injuries. The coroner found multiple clinical and system failures contributed substantially to the death. …
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