88 results
49y · Female·Hypoxic brain injury related to tracheostomy complications in form of airway occ…
Andrea Lester, age 49, suffered a subarachnoid haemorrhage from a PICA aneurysm in March 2018 with delayed diagnosis. Following complex neurosurgery causing Wallenberg syndrome, she required tracheostomy for bulbar dysfu…
45y · Male·Complications of VATS procedure for locally advanced right upper lobe lung adeno…
A 45-year-old man died from complications following VATS lobectomy for lung adenocarcinoma. During initial surgery, the tumour invaded the T6 vertebral body. The surgeon, faced with incomplete tumour resection or vertebr…
76y · Male·Intracranial haemorrhage
Charles Bertram Squires, a 76-year-old prisoner on anticoagulant therapy (apixaban and aspirin), fell and struck his head on 26 January 2017. Nursing staff at the correctional facility inadequately assessed his traumatic…
77y · Male·traumatic closed head injury due to a fall from standing
Alan Maurice Gray, 77, suffered a fall at a service station on 16 September 2020, hitting his head. He called for an ambulance at 7:54pm but paramedics did not arrive until 12:09am (4 hours 15 minutes delay). CT imaging …
81y · Male·acute subdural haematoma
An 81-year-old man suffered a witnessed fall at a shopping centre with head strike to the right parietal region. He presented to the ED with a small haematoma and confusion. The ED team concluded he had a cardiac cause f…
80y · Female·acute subdural haematoma following a fall while on warfarin for atrial fibrillat…
Mrs Bowerman, aged 80, fell at home on warfarin anticoagulation and sustained a minor head injury with no initial neurological signs. Paramedic Turnbull assessed her as requiring no transport (TNR), despite her anticoagu…
47y · Male·sequelae of ruptured brain aneurysm
John Laurenson, a 47-year-old remand prisoner, died from rupture of a brain aneurysm on 20 June 2017, four days after collapsing in his prison cell. He had multiple intracranial aneurysms identified in 2015-2016, includi…
76y · Male·Bronchopneumonia in a man with ischaemic heart disease and treated spinal crush …
John Hayle, a 76-year-old with Alzheimer's dementia, ischaemic heart disease, and spinal fractures sustained a T11/12 flexion-distraction fracture on 9 June 2017. Over three weeks, he developed progressive bilateral lowe…
69y · Female·subdural haematoma
A 69-year-old woman sustained a head injury from a witnessed fall, striking her head on a brick wall. She lost consciousness, experienced headache, vision problems and vomiting. CT imaging at the emergency department mis…
87y · Female·left frontal temporal subdural haematoma following closed head injury sustained …
An 87-year-old woman on irreversible anticoagulation suffered a subdural haematoma from a fall. She presented to a community hospital lucid with stable vitals. A CT scan confirmed acute subdural haematoma. The neurosurgi…
89y · Male·fractured cervical spine (C5 inferior articular process fracture) due to unwitne…
An 89-year-old man with Parkinson's disease fell at home on 16 August 2016, sustaining a cervical spine fracture. Initial CT imaging missed the C5 inferior articular process fracture, reporting only a paraspinal haematom…
53y · Female·cardiorespiratory arrest in a person with blunt force head injury, end-stage liv…
Sharon Bell was found dead in her hallway on 25 May 2013 aged 53. She had end-stage liver disease with hepatic encephalopathy, had suffered recent blunt force head injuries of unclear origin, and had high blood methadone…
34y · Female·Complications of fall with fractured ankle and subsequent deep venous thrombosis…
Anna Bowditch, aged 34, died from complications of deep venous thrombosis (DVT) with pulmonary embolism and paradoxical stroke following elective fracture repair surgery. She had multiple known DVT risk factors: immobili…
62y · Male·cerebral haemorrhage (intracerebral bleed, large lobar within left cerebral hemi…
A 62-year-old man presented to ED with dyspnoea, diaphoresis, and hypertension caused by an evolving cerebral haemorrhage. He was initially misdiagnosed with NSTEMI based on elevated troponin and atrial fibrillation, lea…
5y · Male·complications of blunt force injury to the head
A 5-year-old boy died from complications of blunt force head injury sustained on 19-20 March 2010. He presented to a rural hospital unresponsive, with the initial account not mentioning head trauma. The attending doctor …
43y · Male·Multi-organ failure with coagulopathy secondary to acute exacerbation of chronic…
A 43-year-old man with a colloid cyst of the third ventricle presenting with progressive headache was admitted for planned endoscopic surgery. Surgery was delayed from Friday to Monday due to unavailability of specialist…
41y · Male·large volume thrombotic stroke within the distribution of the right posterior ce…
A 41-year-old man with acute posterior circulation stroke was misdiagnosed as encephalitis despite normal lumbar puncture findings. The critical failure was Dr Reben's failure to diagnose stroke on 7 September and arrang…
41y · Male·Complications of blunt force injuries of the head
Colin Parker, aged 41, suffered an unwitnessed fall with head injury while experiencing syncope from atrial fibrillation in early May 2014. He was admitted to Campbelltown Hospital but his serious intracranial pathology …
76y · Male·Coronary atherosclerosis in the context of obesity, obstructive sleep apnoea, an…
A 76-year-old man with significant comorbidities including severe obstructive sleep apnoea, obesity, aortic stenosis, and ischaemic heart disease died from acute coronary atherosclerosis 36 hours after elective sacroilia…
59y · Female·Global cerebral oedema due to hypoxic cerebral ischaemia following cardiac arres…
59-year-old woman admitted with newly diagnosed grade 4 glioblastoma underwent surgery 16 days later after delays during consultant's planned leave. Post-operative complications included ischaemic stroke confirmed on ima…
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