1,476 results
78y · Female·Multiple organ failure secondary to sepsis and renal failure due to bronchopneum…
A 78-year-old woman with cognitive impairment, depression, and complex care needs fell at home on 11 February 2022. Her sons delayed seeking medical help for 4 days, during which she developed aspiration pneumonia and wa…
64y · Female·Presumed massive pulmonary embolus
Mrs Keating, aged 64, presented to University Hospital Geelong ED with a two-day history of shortness of breath and cough, with known history of pulmonary embolism. Attending physicians appropriately considered PE as dif…
74y · Male·Pulmonary thromboembolism due to right deep vein thrombosis
Richard Holden, aged 74, presented to his GP Dr C. multiple times in August 2020 with progressive shortness of breath and wheeziness. Dr C. diagnosed and treated asthma despite worsening symptoms and failure to respond t…
48y · Male·Pulmonary thromboembolism
Guy Christian Mason, 48, died from a saddle pulmonary embolism on 17 September 2023, three days after discharge from patellar tendon repair surgery. He had sustained a significant knee injury with multiple ligament ruptu…
32y · Female·cerebral venous sinus thrombosis complicated by right intracerebral haemorrhage
Kate Sylvia, 32, presented on 2 December 2021 with severe headache, vomiting, and neurological symptoms including slurred speech. Paramedics transported her to Sefton Park intermediate care instead of hospital. Dr H. mis…
23y · Male·complications of bowel obstruction by adhesions
A 23-year-old man in lawful custody at Parklea Correctional Centre presented on 7 January 2022 with severe chest pain, abdominal pain, vomiting, and dehydration, with a significant history of previous abdominal surgery a…
Male·toxicity caused by a combination of methylamphetamine and morphine
Felipe Esteban Alvarez died on 30 March 2021 from toxicity caused by methylamphetamine and morphine (heroin) ingestion at his unit in Taylor, ACT. He collapsed after self-injecting heroin in the presence of others, inclu…
Male·unascertained
KM, an adult with mental health conditions (anxiety, depression), opioid dependence, and hepatitis C, presented to Alfred Hospital ED on 20 December 2024 with bilateral lower leg cellulitis. After initial IV antibiotics,…
94y · Female·Drug toxicity (baclofen, gabapentin, oxycodone, pregabalin, zolpidem)
A 94-year-old residential aged-care resident died from drug toxicity after receiving another resident's medications. An agency nurse, unfamiliar with the patient and interrupted during medication preparation, failed to p…
69y · Female·Exacerbation of chronic obstructive pulmonary disease and ischaemic heart diseas…
Lynette McHarry, aged 69, died on 15 August 2024 at Casey Hospital following complications from a preventable medication error at Mooraleigh Hostel residential aged care facility. On 4 August, she was mistakenly administ…
21y · Male·Cerebral temporal lobe uncal and cerebellar tonsillar herniation
Brady Hubbard, 21, died from traumatic brain injury with cerebral herniation after falling from an unsecured utility vehicle driven by Andrew Hilfenhaus at West Ulverstone Football Club in June 2023. While riding on the …
61y · Male·bronchopneumonia complicating cerebrovascular accident due to cardioembolism on …
A 61-year-old man with a mechanical aortic valve underwent colonoscopy requiring temporary warfarin cessation. Following the procedure, he was discharged with a plan to recommence warfarin but without clear postoperative…
61y · Male·Exsanguination from sharp force injuries to both arms, dissecting the veins of t…
CG, aged 61, died in Parklea Correctional Centre on 18 May 2024 from hemorrhage due to self-inflicted sharp force injuries. The coroner found multiple clinical and system failures contributed substantially to the death. …
83y · Male·Metastatic melanoma
Maxwell John Beever, aged 83, died from metastatic melanoma on 8 July 2022 while in custody at Robina Hospital. A suspicious skin lesion was documented on 26 February 2021 but not investigated until 26 June 2021, delayin…
69y · Female·Urosepsis secondary to anuric acute renal failure and corona radiata infarct; co…
A 69-year-old diabetic woman presented to Maroondah Hospital Emergency Department on 9 June 2024 with severe right-sided abdominal pain and vomiting. CT imaging at 10:00am confirmed emphysematous pyelitis (gas-forming ki…
Male·phosphine toxicity in a man with atherosclerotic heart disease
Robert Lavars died on 6 September 2022 after deliberately ingesting aluminium phosphide tablets while under police arrest at his home in Shoalwater. He had serious health conditions including strokes, heart disease, and …
68y · Male·Cardiac arrest - unascertained etiology with multiple contributing factors inclu…
Wayne Thomas Kerle, 68, was arrested at his home for cannabis possession. Queensland Ambulance Service paramedics assessed him when he reported respiratory distress but cleared him for police custody after a limited exam…
29y · Male·Cardiac arrhythmia in the context of alcohol withdrawal and chronic alcohol misu…
A 29-year-old man died from cardiac arrhythmia in the context of severe alcohol withdrawal at a correctional facility. Initial assessment correctly identified moderate-to-severe withdrawal (AWS score 8) with seizure hist…
82y · Male·Multiorgan failure due to neurological failure due to Parkinson's disease with a…
Mr M, aged 82, with advanced Parkinson's disease and dementia, developed severe pressure injuries while in residential aged care. A significant sacral pressure wound went undetected until mid-December 2023 and rapidly de…
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
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