2,765 results
29y · Male·Hypoxia as a result of cardiac arrest (ventricular fibrillation) from unknown ca…
David Thomas, 29, collapsed from ventricular fibrillation while exercising at a Melbourne fitness centre on 3 October 2007 and died from hypoxic brain injury. The critical failure was inadequate pre-hospital response: on…
34y · Female·Hanging with combined effects of ethanol and benzodiazepines
Lisa Sharp, 34-year-old woman on a Community Treatment Order for schizophrenia, depression, and anxiety, died by hanging on 16-17 December 2007. She was in severe distress over losing custody of her children, with a cour…
8y · Male·Septic shock consequent on burst appendix with peritonitis
Jacob Belim, aged 8, presented to a GP with appendicitis on 24 March 2009 but the diagnosis was missed. The next day, his treating doctor correctly diagnosed ruptured appendix and referred him urgently to hospital. At Li…
41y · Male·Neck compression subsequent upon hanging
A 41-year-old man with depression, anxiety and prior suicidal ideation died by hanging on the morning of a scheduled psychology appointment. He had been referred by his GP for psychiatric care five days prior following a…
91y · Female·pulmonary thromboembolism and subcutaneous abscess formation complicating pressu…
A 91-year-old woman died from pulmonary thromboembolism and abscess formation complicating untreated ankle fracture and pressure sores. She had sustained a fracture-dislocation of her right ankle after a fall, which she …
63y · Male·cerebral infarction
John Arthur Burns, a 63-year-old man with frontotemporal dementia and motor neurone disease, died from cerebral infarction on 17 September 2006 while in Westminster Aged Care Facility after only 12 days of residence. Des…
60y · Male·cardiorespiratory failure due to malignant pleural effusion due to metastatic ma…
A 60-year-old man with diabetes presented with a plantar heel ulcer in March 2007 that was initially treated as a diabetic foot ulcer. The lesion failed to heal over 16 months despite standard care including wound dressi…
Female·Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perfor…
Two elderly women died following vaginal prolapse surgery performed by the same surgeon, Dr O., with similar mechanisms: bowel perforation leading to peritonitis and sepsis. Mrs Leonard (77) underwent laparoscopic surger…
19y · Male·Drowning due to head injury
19-year-old elite surf competitor Saxon Bird died after being struck in the head by an unmanned ski during the 2010 Australian Surf Life Saving Championships at Kurrawa Beach. He lost consciousness and drowned; his body …
25y · Male·hanging
A 25-year-old university student with a complex history of schizoaffective disorder and substance misuse died by hanging during family leave from a mental health ward. He had been stable on depot antipsychotic medication…
64y · Female·Bilateral pulmonary embolism with left middle cerebral artery/posterior cerebral…
Marlene Kenny, 64, presented to Orbost Hospital on 8 January 2007 with chest tightness, breathing difficulties and low oxygen saturation (83-86%). A doctor diagnosed panic attack and discharged her without investigation.…
82y · Male·closed head injury (subdural haematoma) sustained in a fall
An 82-year-old man on warfarin died from a subdural haematoma sustained in a fall at a rehabilitation centre. He fell while attempting to walk to the toilet unassisted after not being provided with a urinal bottle, despi…
48y · Female·acute myocarditis resulting from systemic viral infection
A 48-year-old Aboriginal woman with chronic diseases (diabetes, COPD, ischaemic heart disease) presented with ongoing chest infection symptoms across multiple clinic visits between 30 March and 4 April 2010. Despite five…
27y · Female·mixed methadone and alcohol intoxication
Susan Patterson, a 27-year-old Aboriginal woman with a history of alcohol and polysubstance use, died from mixed methadone and alcohol intoxication. She consumed an unknown substance from a brown bottle offered by a neig…
Male·Faecal peritonitis due to perforated diverticulum
Michael Sutherland presented to Bega Hospital Emergency Department on 2 March 2006 with severe abdominal pain from diverticulitis with bowel perforation. Dr B., the attending Career Medical Officer, formed an unfounded b…
0y · Female·Hypoxic ischaemic encephalopathy due to true knot in umbilical cord
A term infant died from hypoxic ischaemic encephalopathy caused by a true knot in the umbilical cord. The mother presented in labour with spontaneous rupture of membranes and had a prolonged second stage. Foetal heart ra…
39y · Male·pneumococcal meningitis with severe cerebral oedema due to pneumococcal mastoidi…
Jamie Stuart Bais, a 39-year-old man with acute otitis media and sinusitis, was admitted to Flinders Medical Centre for what was thought to be a straightforward ENT infection. Over 15 days, he developed pneumococcal meni…
42y · Male·Hanging (self-inflicted) while suffering from serious mental illness
Brian Dunningham, aged 42, died by hanging at Bathurst Correctional Complex (9–10 September 2009) while in custody. He had serious mental illness (psychosis, depression) requiring antipsychotic and antidepressant medicat…
40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…
Michael Peter Magro, a 40-year-old male inmate at a correctional facility, died on 27 December 2008 from hypoxic brain injury following cardiac disease and severe pneumonia. Critical failures in prison healthcare were id…
38y · Male·Multiple injuries due to motor vehicle and bicycle collision (rider)
A 38-year-old renal physician and avid cyclist died when struck by a loaded truck towing a trailer at a roundabout in Queensland. The collision occurred because the shoulder of the highway narrowed considerably at the ro…
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