193 results
63y · Female·bile peritonitis as a complication from a laparoscopic cholecystectomy
A 63-year-old woman died from bile peritonitis following laparoscopic cholecystectomy. The surgeon's intraoperative management was appropriate with no identified injuries. However, critical clinical deterioration on post…
62y · Male·multi organ failure due to atypical pneumonia
William Gripton, 62 years old with post-polio syndrome, presented to Kangaroo Island Hospital with upper respiratory tract infection that progressed to atypical pneumonia causing multi-organ failure and death. Critical c…
24y · Male·neck compression due to hanging
A 24-year-old man with depression and anxiety died by hanging in March 2009, three weeks after hospital discharge following an overdose. Critical clinical lessons emerge: (1) discharge summaries from psychiatric admissio…
51y · Female·Complications of anorexia nervosa
A 51-year-old woman with severe anorexia nervosa, BMI 12.1, was admitted to hospital acutely unwell with hypothermia, bradycardia, heart block, and extreme malnutrition. She was discharged after only 2 days with minimal …
0y · Female·perinatal pneumonia in association with meconium aspiration
Baby Sharinka Patricia Little, born prematurely at 35 weeks at Dalwallinu Hospital on 20 March 2008, died from perinatal pneumonia with meconium aspiration the same day. Critical clinical failures occurred during her nin…
63y · Female·Intra-cerebral bleed secondary to thrombocytopenia in a person with prolymphocyt…
Josephine Troy, 63, died on 14 February 2006 at Bunbury Regional Hospital from an intracerebral bleed secondary to thrombocytopenia (platelet count of 1) arising from prolymphocytic leukaemia. She had been in remission f…
Female·diabetic ketoacidosis
Patricia Chan died on 25 August 2006 from diabetic ketoacidosis following dental extraction four days earlier. She had type 2 diabetes. Her condition deteriorated over two days at home, and her husband Duncan Tang was ch…
Male·Suicide: hanging (Al-Akabi, Saunders); diving from balcony (Rauluni)
Three immigration detainees died by suicide at Villawood Detention Centre in Sydney within three months in 2010. Josefa Rauluni (Fijian) jumped from a balcony on 20 September after being informed of imminent removal desp…
36y · Male·infective endocarditis
John Clive Anderson, a 36-year-old prisoner, died from infective endocarditis despite being evaluated 25 times by prison medical officer Dr P. between February and May 2009. Dr P. documented possible infective endocardit…
32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …
A 32-year-old woman with schizophrenia, well-controlled on clozapine, became pregnant. Poor communication between her general practitioners, community mental health service, and the hospital meant the hospital was unawar…
81y · Male·Retropubic and retroperitoneal haemorrhage complicating pelvic fractures with co…
An 81-year-old man died from retropubic and retroperitoneal haemorrhage complicating pelvic fractures sustained in a fall at church. He was on warfarin for atrial fibrillation with an excessive INR of 4.6 at the time of …
70y · Female·Cardiac arrest caused by a combination of gastric haemorrhage and pneumonia exac…
Mrs Kathleen Anne Conlan, 70, died from cardiac arrest caused by gastric haemorrhage and pneumonia on a background of coronary artery disease. She presented with severe epigastric pain and was appropriately admitted for …
56y · Female·pulmonary thromboembolism due to left calf deep vein thrombosis
A 56-year-old woman with bipolar disorder died from pulmonary thromboembolism due to left calf deep vein thrombosis while detained under the Mental Health Act in hospital. She presented with seizures and underwent wrist …
68y · Male·Complications following colon surgery on a background of cirrhosis of the liver;…
Ian Donald Patience, 68, died on 10 June 2007 from complications following colon surgery in the setting of cirrhosis. He underwent right hemicolectomy at Sydney South West Private Hospital on 31 May 2007 for colorectal c…
73y · Female·Bacterial endocarditis organism arising from a staphylococcal infection that ent…
Mary Roberts, aged 73, received a 5-year custodial sentence in September 2004. She had complex medical needs: dementia from previous strokes, diabetes requiring insulin monitoring, and Warfarin use. Justice Health provid…
64y · Male·Large pulmonary embolus (origin undetermined)
Paul Brauer, 64, died of pulmonary embolus at Leeton District Hospital following a complex admission involving psychiatric depression, atrial fibrillation, urinary retention, and multiple comorbidities. The coroner ident…
84y · Female·septicaemia secondary to septic arthritis of the left knee
An 84-year-old woman presented to hospital with acute left knee swelling and pain. Initial assessment at Ashford Hospital ED reasonably excluded septic arthritis based on borderline blood tests and absence of fever, thou…
26y · Female·Streptococcal Sepsis resulting from Skin Ulceration and complications of Cerebra…
Kate Therese Bugmy, a 26-year-old woman with cerebral palsy, epilepsy, and intellectual disability, died on 28 June 2007 of Streptococcal sepsis from infected pressure ulcers. She was cared for at home by her mother Daph…
34y · Female·complications of metastatic rectal cancer
Penelope Dingle died of metastatic rectal cancer on 25 August 2005. She was diagnosed with localised rectal cancer in February 2003 when a potential surgical cure was possible. However, she rejected mainstream treatment …
45y · Male·Bronchopneumonia
Gary Carrick, a 45-year-old man with Down syndrome and severe progressive cervical myelopathy, died from bronchopneumonia. He experienced rapid functional decline from January 2008, including loss of mobility, incontinen…
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