263 results
75y · Female·multiple organ failure due to severe anaemia secondary to blood loss post electi…
A 75-year-old woman died from multiple organ failure due to severe anaemia after elective hysterectomy surgery. Critical failures occurred: the surgical and anaesthetic teams held conflicting understandings about whether…
51y · Male·complications of myocardial infarction in association with ischaemic heart disea…
A 51-year-old prisoner died from complications of myocardial infarction with ischaemic heart disease. He had multiple cardiovascular risk factors including type-2 diabetes, hypertension, high cholesterol, chronic kidney …
68y · Female·Acute myocardial infarction and coronary artery atherosclerosis
A 68-year-old woman presented to St Vincent's Hospital emergency department with upper abdominal and left-sided chest pain following a stationary bicycle fall. Clinicians attributed her symptoms to codeine adverse reacti…
41y · Male·Cardiomegaly in a man with WHO Class III obesity
Michael Suckling, a 41-year-old Aboriginal man, died in prison from cardiomegaly secondary to morbid obesity (BMI 54.5). He gained approximately 117kg during his 3-year incarceration, with rapid initial weight gain from …
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…
5y · Female·myocarditis
A five-year-old girl died from fulminant myocarditis caused by influenza A on 5 July 2022 at Canberra Hospital. The diagnosis was delayed over 7 hours from initial presentation. Critical failures included: ED triage Cate…
31y · Male·Undetermined
Ashley Washington, a 31-year-old Kamilaroi man, died after police restraint and sedation during arrest in Toowoomba. He was apprehended following a report of property theft and stabbed a police dog and officer with sciss…
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…
73y · Male·subdural haematoma from fall
Leonard Athol Long, a 73-year-old on warfarin for mechanical mitral valve replacement, fell twice during hospitalization for urinary tract infection. He was on SMZ-TMP antibiotics, which interact significantly with warfa…
56y · Male·coronary atherosclerosis
Leigh Ronald Roberts, 56-year-old male, died from coronary atherosclerosis with severe stenosis affecting all three main coronary arteries. He presented to his GP on 17 and 21 February 2020 with respiratory symptoms (cou…
70y · Female·Heart failure due to paroxysmal atrial fibrillation treated with flecainide card…
A 70-year-old woman with complex cardiac history including heart failure, paroxysmal atrial fibrillation, and coronary atherosclerosis presented with urinary tract infection and atrial fibrillation on Christmas Day 2021.…
54y · Male·quetiapine toxicity in a man with ischaemic heart disease
Shane Pappas, a 54-year-old man with ischaemic heart disease, died from quetiapine toxicity after deliberately overdosing on multiple medications on 29 June 2021. He had experienced a recent relationship breakdown and pr…
49y · Male·Unascertained - cardiac arrhythmia with terminal aspiration in an overweight man…
Phillip Veltman, 49, died of unascertained cause (likely cardiac arrhythmia with terminal aspiration) while an involuntary psychiatric patient at Bentley Mental Health Services. He presented to Royal Perth Hospital ED on…
44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…
Michael Baker, a 44-year-old Aboriginal man in custody at Lithgow Correctional Centre, died from cardiac arrhythmia on 25 June 2019. He had multiple comorbidities (hypertensive heart disease, obesity, type 2 diabetes, un…
37y · Male·Complications due to atherosclerotic heart disease and dyslipidaemia
Glen Dooley, a 37-year-old Aboriginal man, died of atherosclerotic heart disease and dyslipidaemia while in custody at Darwin Correctional Centre. His death was avoidable. He had abnormal ECGs in 2019 and 2022 that were …
35y · Male·cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory…
35-year-old Mohamed Warwar died in custody at Metropolitan Remand & Reception Centre from cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues an…
67y · Male·Ischaemic heart disease; coronary artery atherosclerosis (stented)
A 67-year-old man with extensive cardiac history presented to the ED with recurrent ischaemic-sounding chest pain. Despite multiple episodes of chest pain during admission, initial ECGs and troponins were normal. Followi…
86y · Female·Cardiogenic shock
Adelaide Wilson, 86 years old, presented to an urgent care centre with two days of chest pain and vomiting. A point-of-care troponin test (i-STAT) returned 0.4 ng/L, interpreted as normal, and she was discharged with gas…
11y · Male·unascertained
An 11-year-old child with Cornelia de Lange Syndrome and severe congenital heart disease died alone at home while his mother was intoxicated and unwell. He had complex care needs and was non-verbal. The Department of Com…
30y · Female·tricuspid valve bacterial endocarditis
Jennifer Collins, a 30-year-old intravenous methylamphetamine user, died from tricuspid valve bacterial endocarditis on 6 September 2018. She presented to Noarlunga Hospital ED on 20 August 2018 with chest tightness, fev…
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