125 results
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…
Male·Hemant Chadha: acute on chronic pneumonia (mycoplasma pneumoniae). Sachintha Bat…
Two young men died after repeated ED presentations were not appropriately managed. Hemant Chadha (38) died of acute pneumonia complicated by possible neurological involvement after being discharged from Lyell McEwin Hosp…
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…
76y · Male·Effects of fire due to home oxygen ignition in the setting of smoking; lung canc…
A 76-year-old man with lung cancer and mesothelioma died from thermal injuries sustained when his home oxygen ignited while smoking. He had been discharged on self-funded home oxygen despite a recent smoking history, aft…
24y · Male·Cardiac arrest in a man with Sotos syndrome and multiple comorbidities, includin…
Joshua Fredrik Van Malssen, a 24-year-old man with Sotos syndrome, complex cardiac disease, asthma, and obesity, died from cardiac arrest after being restrained in the prone position during a lawful arrest by Public Tran…
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 …
55y · Female·acute necrotising bronchopneumonia
MQ, 55, died of acute necrotising bronchopneumonia on 2-3 March 2023. She had developed community-acquired pneumonia from 21 February 2023, presenting initially with referred shoulder pain (later recognised as diaphragma…
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…
78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…
78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). T…
52y · Male·Aspiration pneumonia in a man with end stage Huntington's disease
Christopher Kuric, a 52-year-old man with end-stage Huntington's disease residing in specialist residential care, died of aspiration pneumonia. He had documented swallowing difficulties managed by speech pathology and di…
65y · Male·Pneumonia, due to chronic lung disease with atherosclerotic cardiovascular disea…
A 65-year-old man with severe chronic lung disease, COPD, and coronary artery disease died at home. Evidence suggests he deliberately ingested benzodiazepines and possibly other substances in a self-harm attempt. However…
3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…
Jade, a 3-year-old First Nations child, died from bilateral bronchopneumonia with neglect as a significant contributing factor. Her death was wholly preventable. The coroner identified critical failures: DCJ's Muswellbro…
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…
78y · Female·Bronchopneumonia
CFT, a 78-year-old woman with chronic schizophrenia, intellectual disability, and dementia, died of bronchopneumonia with hypothermia and coronary atherosclerosis. She lived with her nephew RDS who was her carer. Multipl…
46y · Male·Respiratory arrest secondary to acute exacerbation of bronchial asthma caused by…
A 46-year-old man with poorly controlled asthma and known ibuprofen hypersensitivity presented to a rural hospital with chest pain. A remote on-call doctor prescribed aspirin without knowledge of the allergy or availabil…
68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pul…
Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in…
0y · Male·Trisomy 21 with complex cardiac anomalies complicated by pulmonary hypertension,…
Baby G, born with Trisomy 21 (Down Syndrome) and complex cardiac anomalies, died at Royal Darwin Hospital on 18 March 2023 aged 6 months. The coroner found that non-invasive prenatal testing (NIPT) should have been offer…
61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed
A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…
4y · Female·hypoxic brain injuries
A 4-month-old girl died from hypoxic brain injury following an unexplained, unnatural restriction of oxygen on 13 May 2017. She was found unresponsive at home and despite resuscitation, suffered irreversible brain damage…
47y · Male·Sudden cardiac death in association with COVID-19 infection
Alen Imbrisak, a 47-year-old man incarcerated at Junee Correctional Centre, died on 26 January 2022 from sudden cardiac death in association with COVID-19 infection. He tested positive on 25 January 2022 during a centre-…
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