193 results
77y · Female·Large acute subdural haemorrhage leading to uncal herniation subsequent to an ac…
Barbara Sheedy, 77, died from acute subdural haemorrhage following an accidental fall in hospital. She fell while using a wheeled walker and initially appeared uninjured with normal neurological examination. However, she…
83y · Male·pneumonia and severe acute respiratory distress syndrome caused by Legionella ba…
An 83-year-old man died from pneumonia and respiratory distress caused by Legionella bacterium. He presented with abdominal symptoms and was initially misdiagnosed as having aspiration pneumonia rather than community-acq…
55y · Male·cardiac tamponade resulting from proximal aortic dissection due to hypertension
A 55-year-old man presenting with acute severe chest pain, headache and jaw pain to a regional hospital was evaluated for aortic dissection. A CT angiogram was performed but the radiologist's verbal report contained ambi…
60y · Male·Congestive Cardiac Failure
A 60-year-old Aboriginal man with end-stage COPD, congestive cardiac failure, and ischaemic heart disease died in prison custody. He likely suffered cardiac collapse around 8:30-9:00pm on 25 October 2014, pressed his cel…
Organising pneumonia (Sandra Boney and Norman Boney); Organising pneumonia compl…
Three Aboriginal Australians from Walli Reserve (Sandra Boney, 40; Norman Boney, 46; Roger Adams, 37) died within two months in early 2015 following consumption of illegally home-distilled methanol-containing alcohol ('m…
33y · Male·Opiate toxicity
A 33-year-old man with previously unrecognized obstructive sleep apnoea was admitted with severe headache. The treating physician prescribed a complex regimen of escalating opiate doses including both slow-release (MS Co…
86y · Female·Multiple organ failure following sepsis due to infected pressure ulcer of the hi…
Jean May Reardon, an 86-year-old widow living at home with limited mobility, required care from her adult children. Following an influenza illness, she developed multiple pressure ulcers within 7-10 days, particularly on…
51y · Male·Pericardial tamponade complicating Type I aortic dissection in the setting of lo…
Mark Gordon, 51, presented to Royal Hobart Hospital Emergency Department on 20 March 2015 with sudden onset chest pain. Initial assessment suspected acute coronary syndrome with elevated troponin. Over 36 hours he experi…
84y · Female·Myocardial infarction
Shirley McGuane, 84, died from myocardial infarction following elective proctocolectomy. Post-operative care was deficient: chest pain on day 2 post-op with ECG showing atrial fibrillation and new right bundle-branch blo…
44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)
Jimmy James, a 44-year-old man, died from pneumonia with multiple left-sided rib fractures secondary to a physical assault. He presented to Westmead Hospital ED with clinical signs of septic shock (tachypnoea, hypoxia, h…
32y · Female·massive postpartum intracerebral haemorrhage of spontaneous hypertensive origin
A 32-year-old woman with Factor V Leiden mutation died from a massive postpartum intracerebral haemorrhage of hypertensive origin five hours after delivering twins. She had been diagnosed with pregnancy-induced hypertens…
33y · Male·presumed fatal cardiac arrhythmia in the presence of coronary artery atheroscler…
Dr D., a 33-year-old physicist, was admitted to Hornsby Hospital on 27 December 2012 with abdominal pain, nausea, vomiting and joint pain. His presentation included hypotension (97/61), tachycardia (116/min), hyponatraem…
80y · Female·subdural haematoma due to closed head injury sustained in a fall from bed in hos…
An 80-year-old woman with chronic heart failure admitted to hospital fell from bed and hit her head. Although nursing staff were concerned about a possible head injury, the House Medical Officer incorrectly concluded no …
52y · Female·intracerebral haemorrhage in a lady with underlying cerebrovascular disease and …
A 52-year-old woman underwent right carotid endarterectomy for high-grade stenosis. Post-operatively she developed escalating blood pressure readings (160–220 mmHg), headaches, nausea, agitation, and abnormal behaviour o…
56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy
A 56-year-old woman presented to Knox Private Hospital with severe headache and eye symptoms on 16 June 2007. An ED physician diagnosed ischaemic stroke based on a subtle CT finding in the absence of focal neurological s…
60y · Female·hanging
Margaret McCall, a 60-year-old woman with chronic regional pain syndrome and longstanding anxiety and depression, died by hanging. She received multiple ketamine infusions for pain management, with cessation of fentanyl …
90y · Female·Infected sacral ulcer and fluid imbalances in the context of dementia
A 90-year-old woman with dementia, admitted to aged care in September 2012, developed a large necrotic sacral pressure ulcer despite nursing interventions. She was markedly dehydrated and malnourished, repeatedly refusin…
21y · Male·Sepsis caused by Leptospirosis (Graeme Gulliver); Group A streptococcal meningit…
Three young patients died from severe bacterial infections at rural Queensland hospitals (Mossman and Atherton). All three received delayed diagnoses and treatment. The first patient (21-year-old with leptospirosis) pres…
76y · Male·exsanguination secondary to pulmonary aortic fistula and thoracic aorta aneurysm…
Allan Phipps was a 76-year-old man with a known thoracic aortic aneurysm and severe depression admitted to Austin Hospital in October 2012 for unstable angina and depression management. His aneurysm, discovered in March …
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…
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