0y · Female·Severe hypoxic ischaemic encephalopathy, result of brain injury as a consequence…
Lucy Campbell, a neonate born on 16 February 2024, died from severe hypoxic ischaemic encephalopathy following a complicated assisted vaginal birth at a rural level 3 hospital. The mother underwent induction of labour at…
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…
41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…
Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…
74y · Male·Acute myocardial infarction complicated by multiple organ failure
Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…
60y · Male·Pulmonary tuberculosis in a man with chronic obstructive pulmonary disease, with…
A 60-year-old man remanded in custody died from pulmonary tuberculosis complicated by severe COPD. Key clinical issues included: delayed diagnosis (TB not suspected at intake despite respiratory symptoms), patient's refu…
78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …
A 78-year-old woman died from hypoxic ischaemic encephalopathy following an acute post-surgical arterial bleed that obstructed her airway after hemithyroidectomy. The bleeding complication occurred when she coughed after…
22y · Male·Airway obstruction due to laryngeal abscess and laryngeal chondronecrosis due to…
Kyle Gallagher, age 22, died from airway obstruction due to laryngeal abscess and chondronecrosis following a motorcycle accident. A CT scan on 13 July 2023 showed a critically narrowed (3mm) subglottic airway with suspe…
42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…
Eve Brown, a 42-year-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ri…
17y · Male·Hypoxic Ischaemic Encephalopathy Complicating Anaphylaxis
James Tsindos, a 17-year-old with known nut allergy and mild asthma, experienced anaphylaxis after inadvertently ingesting cashews in a vegan restaurant meal on 27 May 2021. Ambulance paramedics administered two doses of…
44y · Male·Sepsis due to Streptococcus pyogenes (Group A Streptococcus) septicaemia complic…
Brian Dean, a 44-year-old with obesity, presented to hospital on 1 July 2023 with influenza A and signs of shock (tachycardia, hypotension, elevated lactate). He was treated with fluids and discharged the next morning ap…
15y · Male·Cardiorespiratory arrest of unknown aetiology complicating hypoxic ischaemic enc…
Max McKenzie, a 15-year-old with asthma and food allergies, died from cardiorespiratory arrest complicating hypoxic ischaemic encephalopathy after severe refractory anaphylaxis. After eating apple crumble containing nuts…
43y · Male·Bilateral pulmonary thrombo-emboli; contributory factors included obesity, coron…
Paul Harris, a 43-year-old Aboriginal man, died from bilateral pulmonary emboli while hospitalized at Hay District Hospital. He presented in September 2019 with pneumonia and Q fever (occupational exposure from kangaroo …
49y · Female·Hypoxia due to complications following incision and drainage of a right buttock …
A 48-year-old woman with multiple comorbidities (diabetes, COPD, chronic kidney disease, ischaemic heart disease) died following complications of anaesthesia during incision and drainage of a buttock abscess. Critical fa…
33y · Male·Complications of out of hospital cardiac arrest in a man with atherosclerotic ca…
A 33-year-old Indigenous man with Type 2 diabetes, hypertension and dyslipidemia collapsed while playing football in a prison in July 2023, sustaining an out-of-hospital cardiac arrest from which he did not recover. Auto…
30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…
Karl Steinhauser, a 30-year-old man with schizoaffective disorder and polysubstance misuse, died from pulmonary thromboembolism on 12 March 2023 while under Mental Health Act care. After two weeks of increasingly challen…
Male·Little Brother: multi-organ dysfunction due to hypothermia with contributing con…
Two Aboriginal brothers with chronic alcohol use disorder and cognitive impairment died in July and September 2023 in Alice Springs Hospital. Both had adult guardianship orders, NDIS packages, and aged care assessments r…
43y · Female·Subarachnoid haemorrhage due to a ruptured berry aneurysm
Trina McGrady, a 43-year-old Goomeroi woman, died from subarachnoid haemorrhage due to a ruptured berry aneurysm on 15 September 2020. She had been admitted to John Hunter Hospital following incidental discovery of two l…
16y · Male·complications of ligature compression of the neck (hanging)
Cleveland Keith Dodd, aged 16, died on 19 October 2023 from complications of ligature compression of the neck (hanging) while in custody at Unit 18, a youth detention facility within Casuarina Prison, Western Australia. …
65y · Female·Combined effects of acute pneumonia, pancreatitis, urinary tract infection, and …
A 65-year-old woman with chronic alcohol use disorder, multiple comorbidities, and progressive functional decline died from combined effects of pneumonia, pancreatitis, urinary tract infection, and severe pressure ulcers…
32y · Female·Cardiac arrest due to hypoxia caused by dynamic hyperinflation arising from comp…
A 32-year-old woman with Sponastrime Dysplasia (a rare genetic bone disorder) died during elective bariatric surgery. She had undiagnosed subglottic stenosis (airway narrowing) and tracheobronchomalacia. Critical clinica…
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