447 results
26y · Male·Multi-organ failure due to pneumococcal septic shock
A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…
73y · Male·Complications of cervical fractures and spinal injury (operated), sustained in a…
A 73-year-old man with multiple comorbidities (diabetes, cardiac disease, liver cancer) slipped on wet tiles outside McDonald's and sustained cervical and thoracic spine fractures with spinal cord injury. Attending param…
23y · Female·hypoxic ischemic encephalopathy and aspiration pneumonia as a result of hanging
BQ was a 23-year-old Aboriginal woman who died by hanging on the Paringa Ward at Cumberland Hospital while detained as an involuntary mental health patient. She had a complex psychiatric history with schizophrenia and bo…
0y · Female·Unascertained
A 9-month-old girl died suddenly on 23 July 2018 following multiple head injuries from blunt force trauma sustained shortly before death. She had presented to medical practitioners multiple times in the preceding weeks w…
46y · Female·Hepatic encephalopathy due to decompensated Child-Pugh C cirrhosis and meningiti…
This combined coronial finding examines three deaths at the Centre for National Resilience (CNR), a COVID-19 quarantine facility in Howard Springs. Ms Dick died from rapidly progressive melioidosis. David Hardy died from…
42y · Female·pneumonia with diffuse alveolar damage in the setting of mixed drug toxicity (Ba…
Allyson Bailey, a 42-year-old woman with complex polysubstance use disorder and borderline personality disorder, died from pneumonia with diffuse alveolar damage complicated by mixed drug toxicity (baclofen and pregabali…
82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…
Winifred Carpenter, 82, died 11 days after a right hemicolectomy for colon cancer from peritonitis due to anastomotic leak. Critical failures occurred on discharge day (10 March 2023): clinicians did not recognize her de…
76y · Female·multi-organ failure and sepsis due to complications of cholecystectomy
A 76-year-old woman died from multi-organ failure and sepsis following a laparoscopic cholecystectomy at a rural hospital. During surgery, the surgeon became misoriented in the inflamed surgical field and divided the com…
42y · Male·Multiple organ failure due to iatrogenic phenol overdose due to metastatic pancr…
A 42-year-old man with metastatic pancreatic cancer died from multiple organ failure caused by iatrogenic phenol overdose during a celiac plexus block for pain management. The radiologist administered 40ml of 80% phenol …
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…
41y · Female·frontal lobe ischaemic infarcts (strokes) caused by cerebral artery vasospasm co…
A 41-year-old woman died from frontal lobe ischaemic infarcts caused by cerebral vasospasm complicating subarachnoid haemorrhage from a ruptured aneurysm. She presented to multiple healthcare providers over five days wit…
69y · Female·Multiple organ failure due to secondary haemochromatosis (transfusion-associated…
Mrs Vicki Dow, 69, died from multiple organ failure secondary to iron overload (transfusion-associated haemochromatosis) from treatment of myelodysplastic syndrome. She had declined iron chelation therapy for 19 months d…
62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…
A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…
69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…
Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…
69y · Male·thoracic aortic aneurysm with dissection
Peter Hanisch, a 69-year-old man, died from thoracic aortic aneurysm with dissection on 22 August 2021. He presented to Calvary Hospital on 19 August 2021 with sudden chest discomfort and neurological symptoms. A CT angi…
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…
43y · Male·Hypoxic ischaemic encephalopathy, due to or as consequence of, cardiac arrest of…
A 43-year-old man with methamphetamine toxicity was restrained by police and given two doses of droperidol by paramedics who failed to recognize he was critically unwell. The first dose was clinically indicated, but the …
62y · Male·cardiac arrhythmia secondary to prolongation of the QT interval
NL, a 62-year-old man with schizoaffective disorder and hypothyroidism, died of cardiac arrhythmia secondary to QT prolongation while an involuntary mental health inpatient. He had a known history of non-compliance with …
66y · Female·Hypoxic-ischaemic encephalopathy
A 66-year-old woman with COPD, obstructive sleep apnoea, and obesity underwent routine knee surgery at Royal Darwin Hospital. Post-operative care was inadequate. Despite dropping oxygen saturations to 88% when sedated an…
77y · Female·intracranial haemorrhage (subdural, intraventricular and brainstem)
A 77-year-old woman fell from a ladder on 12 December 2022, suffering loss of consciousness and rib fractures. No brain CT scan was performed at Mersey Community Hospital despite the mechanism of injury and unconsciousne…
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