2,762 results
40y · Male·Subarachnoid haemorrhage due to ruptured right middle cerebral artery aneurysm
A 40-year-old man presented to the ED with sudden-onset severe headache, slurred speech, and vomiting. He was appropriately triaged and quickly diagnosed with subarachnoid haemorrhage due to ruptured middle cerebral arte…
67y · Male·Ingestion of liniment (methyl salicylate) resulting in seizures and cardiac arre…
Kevin Chuter, a 67-year-old man with severe intellectual disability and no speech, died from ingestion of liniment (methyl salicylate in vegetable oil) on 8 May 2005. While in a community residential unit's care at a foo…
54y · Male·Unascertained
A 54-year-old man with HIV, hepatitis C, cirrhosis, and significant immunocompromise presented with acute sepsis on 23 December 2016. Despite rapid ambulance response with sepsis protocol initiation and ICU-level aggress…
78y · Male·Complications of blood loss from femoral fracture sustained in harness riding in…
A 78-year-old man with ischaemic heart disease on warfarin sustained a compound femoral fracture with massive bleeding after a harness racing accident in a rural location. Despite exemplary prehospital care and timely he…
53y · Male·fentanyl and oxycodone toxicity
Stephen Robert Atkins, 53, died from fentanyl and oxycodone toxicity after admission to Flinders Medical Centre for investigation of Horner's syndrome and radiculopathy. Over three days, escalating opioid doses were pres…
Female·Intrauterine pneumonia and meconium aspiration complicating intrauterine growth …
Baby W was born at 37+5 weeks in an ambulance and died at Bendigo Hospital from intrauterine pneumonia and meconium aspiration secondary to intrauterine growth restriction related to maternal amphetamine use. The mother …
70y · Male·combined effects of severe pulmonary emphysema, ischaemic heart disease and rece…
A 70-year-old man with severe COPD, dementia and a history of sexually inappropriate behaviour died following an assault by another resident with dementia. The coroner found institutional failures in care standards inclu…
35y · Female·Pulmonary thromboembolus and pulmonary infarction
A 35-year-old woman at 11 weeks gestation presented to Royal Women's Hospital Emergency Care on 3 September 2012 with chest and rib pain following severe vomiting. Dr M., a junior resident working alone overnight, assess…
43y · Female·acute toxic effects of amitriptyline
A 43-year-old woman with depression was admitted to Gold Coast University Hospital with suspected amitriptyline overdose. After 11 hours of ED monitoring, she was medically cleared and transferred to a mental health asse…
13y · Female·Hanging
Melissa Standen, a 13-year-old with profound physical and cognitive disabilities (mosaicism), died from hanging at Westmead Children's Hospital after falling from a hospital bed at Allowah respite facility. She became en…
63y · Female·disseminated metastatic carcinoma of unknown primary in a woman with multiple sc…
Pamella Rees, a 63-year-old woman with longstanding multiple sclerosis, died on 30 June 2014 from disseminated metastatic carcinoma of unknown primary. Her cancer went undiagnosed despite regular GP contact. In her final…
67y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …
David Fensom, 67, underwent elective fundoplication for hiatus hernia and reflux on 21 September 2010. He developed severe right-sided abdominal pain post-operatively. A laparoscopy on 8 October misinterpreted findings a…
77y · Male·sepsis due to retroperitoneal collection after biliary stent insertion on a back…
A 77-year-old Aboriginal man died from sepsis following a percutaneous transhepatic cholangiography (PTC) procedure that perforated his duodenum. Critical failures included: delayed diagnosis and treatment of peritonitis…
0y · Female·Intracranial and intrapulmonary haemorrhage due to traumatic head injury from fa…
Baby M died shortly after birth on 11 February 2016 at Gladstone Base Hospital from intracranial and intrapulmonary haemorrhage due to traumatic head injury from a fall, complicated by Group B Streptococcal sepsis. A nur…
84y · Female·left lower lung bronchopneumonia in conjunction with small distal pulmonary embo…
An 84-year-old woman with comorbidities sustained right shoulder and pelvic fractures from an accidental fall. She presented to ED with low oxygen saturation (77%) requiring supplemental oxygen. Despite these injuries an…
44y · Male·mixed drug toxicity
Michael Allan Steer, aged 44, died from mixed drug toxicity after ingesting excess prescription medication (quetiapine, codeine, diazepam, fluoxetine). He had complex psychiatric history with factitious and somatic disor…
87y · Female·intentional inhalation of tissue paper leading to upper airway obstruction and h…
Paquita Goldberg, an 87-year-old woman with dementia, BPSD, and paranoia, died from intentional inhalation of tissue paper while admitted to Baringa aged psychiatry unit under a Mental Health Act order. Over 7-8 February…
49y · Female·Motor vehicle accident related multi trauma including a severe head injury
Lynette Roberts, a 49-year-old with schizophrenia, died from motor vehicle collision while wandering aimlessly on a main street in Dunolly on 16 December 2010. She had blood alcohol level 0.16% and was wearing inappropri…
38y · Male·Multidrug toxicity
A 38-year-old man with multiple drug dependencies (alcohol, opioids, benzodiazepines) was admitted to a drug withdrawal facility for assisted detoxification. He received buprenorphine for opioid withdrawal management alo…
54y · Male·Pneumonia due to Staphylococcus aureus
A 54-year-old man died in custody from Staphylococcus aureus pneumonia. Over 11 days before death, he presented multiple times with respiratory symptoms and requested antibiotics, but was never seen by a doctor. Key clin…
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