34 results
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…
67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…
Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pa…
81y · Male·Community acquired pneumonia in a man with acute on chronic renal failure
An 81-year-old man with chronic respiratory disease and renal failure died from community-acquired pneumonia complicated by acute-on-chronic renal failure. He presented to hospital on 25 April 2023 with respiratory failu…
83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)
An 83-year-old male prisoner died from complications of a ruptured abdominal aortic aneurysm (AAA) after a 5-month delay in diagnostic confirmation and treatment. An incidental finding of an 8.7 cm AAA was identified on …
32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome
Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included…
64y · Male·Complications of metformin toxicity on a background of undiagnosed renal impairm…
Peter Gretton, a 64-year-old man imprisoned at Junee Correctional Centre, died from metformin toxicity complicated by acute renal impairment and severe lactic acidosis. His renal function deteriorated in the three to fou…
74y · Male·Intra-abdominal haemorrhage complicating elective umbilical hernia repair
A 74-year-old man with significant cardiac history (atrial fibrillation, dilated cardiomyopathy, pacemaker) underwent elective umbilical hernia repair. Intraoperatively, unexpected ascites was discovered and partially dr…
75y · Male·multifactorial causes on a background of ischaemic heart disease, generalised va…
Robert Bischard, a 75-year-old man with multiple complex comorbidities including coronary artery disease, chronic kidney disease, and diabetes, died five days after elective right total knee replacement surgery. The coro…
41y · Male·heart failure related to exsanguination due to traumatic rupture of an arteriove…
Nicholas Summers, a 41-year-old kidney transplant recipient, died from traumatic rupture of an arteriovenous fistula with massive hemorrhage on 16 February 2016. He had returned to Tasmania under nephrologist Dr Mathew's…
66y · Male·Bronchopneumonia and influenza A complicating cardiac and renal failure associat…
A 66-year-old man with cryoglobulinaemic vasculitis secondary to non-Hodgkin's lymphoma died from bronchopneumonia and influenza A complicating cardiac and renal failure. He developed delirium, agitation and paranoia dur…
16y · Male·pulmonary embolism secondary to nephrotic syndrome
Dylan Riley, a 16-year-old with steroid-responsive minimal change nephrotic syndrome, died from a massive pulmonary embolism (PE) on 1 August 2015. He presented to Rockingham Hospital with dyspnoea, hypoxia, tachycardia …
80y · Male·Bronchopneumonia complicating terminal palliative care in an elderly man with ch…
Aurelio Monterlegre Cruz, an 80-year-old man with complex medical conditions including chronic renal failure, ischaemic heart disease, diabetes, and COPD, died of bronchopneumonia complicating terminal palliative care wh…
55y · Male·probable sepsis in the setting of immunosuppression, a skin wound and chronic di…
David Paul Unwin, a 55-year-old kidney transplant recipient with polycystic kidney disease, died of sepsis in January 2017. He presented with progressive symptoms including chronic diarrhoea, weight loss (16kg in 8 weeks…
71y · Male·cardiac arrest due to hyperkalemia due to acute on chronic renal failure, with r…
John Bell, a 71-year-old man with history of bowel cancer, ischaemic heart disease, and chronic renal failure, underwent elective ileostomy reversal surgery. He died from cardiac arrest due to hyperkalemia and metabolic …
86y · Male·Aspiration Pneumonia secondary to Recurrent Colorectal Carcinoma
An 86-year-old man died from aspiration pneumonia following bowel preparation for elective colonoscopy. He was admitted to an outlying ward rather than the gastroenterology unit, where nursing staff documented multiple e…
75y · Female·pyelonephritis and pneumonia
Molly Jessie Smith, a 75-year-old woman with longstanding severe mental illness, died of pyelonephritis and pneumonia on 16 August 2009. She had been in state psychiatric care continuously for 53 years. During her final …
76y · Female·Acute renal failure due to dehydration due to upper gastrointestinal bleed
A 76-year-old woman with chronic pain was admitted to a small rural hospital on 1 April 2015 with haematemesis secondary to NSAID use. Blood tests were ordered on admission but not transported to the district hospital fo…
73y · Female·Multiple organ failure due to or as a consequence of sepsis due to or as a conse…
73-year-old woman died 12 days after elective colorectal surgery for synchronous caecal and rectal tumours. Post-operatively, she developed persistent low urine output and intermittent hypotension managed with repeated f…
75y · Male·left retroperitoneal haemorrhage associated with lumbar spine surgery
A 75-year-old man with complex comorbidities including Parkinson's disease and cognitive impairment underwent two-stage lumbar spine surgery for degenerative disc disease with stenosis. Post-operatively, he developed a r…
87y · Female·Multiple opioid drug toxicity (morphine and fentanyl) in combination with conges…
An 87-year-old woman with multiple comorbidities (ischaemic heart disease, emphysema, chronic kidney disease) was discharged home for palliative care after a hospital admission. Her family administered excessive doses of…
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