182 results
23y · Female·complications of ruptured ectopic pregnancy with massive intra-abdominal haemorr…
A 23-year-old woman with a ruptured ectopic pregnancy at a rural hospital required urgent transfer to a tertiary centre. The initial response was classified as routine, and the first ambulance crew arrived late without a…
44y · Male·acute myocardial ischaemia due to coronary artery occlusion due to thrombosis an…
Peter Howlett, a 44-year-old male, died of acute myocardial infarction on 21 April 2006 after a 54-minute delay in ambulance arrival. His wife called Triple 0 reporting back pain radiating to chest at 7:20 am. Critical c…
35y · Female·pulmonary thrombo-emboli
A 35-year-old woman with treatment-resistant schizophrenia detained under Mental Health Act died from pulmonary thromboembolism while an inpatient in a psychiatric ward. In the final days, she reported leg pain and possi…
18y · Male·acute multiple drug toxicity
Matthew Hinton, an 18-year-old male, died from acute multiple drug toxicity after consuming nine LSD tablets and methamphetamine. Police attended at approximately 5:30am when called to a disturbance, but a critical delay…
59y · Male·ischaemic heart disease due to coronary atherosclerosis
Brian Raymond Turner, 59, died from ischaemic heart disease due to coronary atherosclerosis following an out-of-hospital cardiac arrest in a medical clinic car park. He experienced symptoms of chest discomfort and breath…
2y · Female·Drowning in an above-ground swimming pool
Hannah Plint, a 2½-year-old, died from drowning after accessing an above-ground pool by dragging a chair to the gate and opening it unsupervised. Her mother was inside with a younger sibling. The pool fence and gate sepa…
26y · Male·Air embolism due to ruptured spleen (surgery) due to motorcycle accident
John Mathers, 26, died from air embolism during emergency surgery following severe motorcycle trauma. A sedan turned across his path; despite heavy braking, he collided and suffered extensive injuries including ruptured …
63y · Male·uncontrolled haemorrhage from ruptured aortic aneurysm
A 63-year-old man presented with sudden back pain on 6 March 2004. Ambulance officers attended twice; on the first visit they did not transport him to hospital despite his request, misattributing his symptoms to musculos…
37y · Male·dehydration/heat-related death
A 37-year-old man died from dehydration and heat-related illness after collapsing in a sweat lodge during a vision quest ceremony in remote South Australia. He remained unconscious after removal from the lodge, but the g…
16y · Female·intra-abdominal haemorrhage due to ruptured spleen
A 16-year-old girl died from intra-abdominal haemorrhage due to ruptured spleen following a car rollover. She was transported by ambulance to the nearest hospital (Renmark) rather than the better-equipped Berri Hospital,…
58y · Male·Multiple injuries occasioned in a motor vehicle accident (broken neck, ruptured …
Clifford Brown, an Aboriginal man aged 58, died from multiple injuries sustained in a motor vehicle accident on 18 December 2004 at Barrow Creek, NT. The central clinical issue was the inadequate emergency assessment and…
81y · Female·aspiration pneumonia, exacerbation of chronic obstructive airways disease (emphy…
Patricia Nina George, an 81-year-old woman detained under mental health legislation at Glenside Campus, died from aspiration pneumonia, COPD exacerbation and congestive heart failure. A critical ambulance transfer delay …
37y · Male·Coronary Atherosclerosis
Muhammad Heri, a 37-year-old Indonesian fisherman, died from coronary atherosclerosis while detained in Darwin Harbour on 28 April 2005. He had been held on his fishing vessel for 7 days without medical examination follo…
25y · Male·acute heat stroke
Trooper Angus Lawrence, a 25-year-old soldier, died from acute heat stroke on 10 November 2004 during a military training exercise at Mount Bundey, NT. He collapsed during a patrol and despite rapid evacuation and intens…
31y · Male·Injuries sustained as a consequence of helicopter crash into water
Three emergency service personnel—pilot Andrew Carpenter (31), paramedic Craig Liddington (31), and crewman Stewart Eva (31)—died in a helicopter crash on 17 October 2003 during a night VFR flight to retrieve a patient w…
35y · Male·left lower lobe pneumonia
Stephen John Power died of left lower lobe pneumonia on 5 September 2003 after two failed emergency calls requesting ambulance assistance. On Thursday 4 September, dispatcher Coralie Holland failed to send an ambulance d…
37y · Male·Acute Aspiration Pneumonitis following on Quetiapine Ingestion
Paul John Long, a 37-year-old man with chronic schizoaffective disorder and alcohol dependence, died on 4 November 2002 from acute aspiration pneumonitis following quetiapine overdose. After presenting to Avro Clinic in …
29y · Male·hanging
A 29-year-old man remanded in custody at Adelaide Remand Centre died by hanging on 15 January 2000. At admission, he denied self-harm risk and psychiatric history; no warning signs were identified. He was found hanging f…
14y · Male·Loss of blood arising from incised wound to the left arm (cubital fossa)
A 14-year-old Aboriginal petrol sniffer brought to a remote outstation (Ilpurla) without pre-arrangement died from massive haemorrhage following a self-inflicted laceration to his arm. Clinical lessons: petrol sniffers i…
51y · Male·Complications of chronic ethanol use
EH was a 51-year-old man with chronic alcohol dependence, liver cirrhosis, and recent hip fracture complications who died at home on 1 November 2022 whilst waiting for an ambulance. He had self-discharged from St Vincent…
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