65 results
84y · Female·complications of a fractured left hip suffered in an unwitnessed fall in aged ca…
An 84-year-old woman with dementia and osteoporosis residing in aged care suffered an unwitnessed fall in a corridor, sustaining a left hip fracture. She underwent high-risk surgical repair on day 3 post-fall. Post-opera…
56y · Male·Complications of atraumatic bilateral femoral fractures (repaired) during a seiz…
Mark O'Brien, a 56-year-old man with Down syndrome and dementia, sustained multiple seizure-related bilateral femoral fractures. A subtle posterior cortical fracture to his left femur, sustained during a seizure on 15 Ju…
36y · Male·Combined drug toxicity (pregabalin, morphine, amitriptyline)
A 36-year-old motor mechanic with chronic pain from a 2014 knee injury died from combined drug toxicity (pregabalin, morphine, amitriptyline). His general practitioner, Dr Schneider, prescribed excessive amounts of multi…
21y · Female·pulmonary embolism in association with deep vein thrombosis of the left leg
A 21-year-old woman died from pulmonary embolism associated with deep vein thrombosis following ankle fracture surgery and immobilisation. She was discharged without thromboprophylaxis despite multiple VTE risk factors (…
63y · Female·Pulmonary thromboembolism
A 63-year-old woman died from pulmonary thromboembolism within 24 hours of bilateral total knee arthroplasty despite aspirin and sequential compression devices. The surgeon assessed her as standard risk and did not presc…
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…
36y · Male·pulmonary embolism due to right deep vein thrombosis following repair of rupture…
Aaron Frith, a 36-year-old man with obesity and hypertension, sustained a ruptured right Achilles tendon on 28 August 2018. He underwent surgical repair on 15 September 2018 and was discharged on aspirin prophylaxis. He …
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…
24y · Male·Peritonitis secondary to a perforation of the small bowel
Nicholas Wells, a 24-year-old man, died from peritonitis secondary to small bowel perforation sustained in a motor vehicle accident. Although he was suspected of having a bowel injury at 11am on admission, he was placed …
51y · Male·pulmonary thromboembolus secondary to left deep vein thrombosis
Darren Templeton, a 51-year-old man with obesity (BMI 31.5), died of pulmonary thromboembolism and left deep vein thrombosis six days after undergoing left knee arthroscopy. Critical clinical lessons: (1) VTE risk assess…
59y · Male·pulmonary thromboemboli due to deep vein thrombosis following right hip replacem…
A 59-year-old man died from pulmonary thromboembolism following right hip replacement surgery. He had mild polycythaemia and elevated BMI (33.26), both risk factors for deep vein thrombosis. Pre-operatively he was classi…
88y · Female·Sepsis complicated by multiple organ failure in a woman with comorbidities in th…
An 88-year-old woman died from sepsis with multiple organ failure following shoulder surgery. She developed an undiagnosed urinary tract infection after placement of an indwelling catheter. Critical failures included: in…
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…
54y · Male·aspiration pneumonia caused by multiple drug toxicity
Paul Lau, aged 54, died from aspiration pneumonia caused by opioid toxicity following ACL reconstruction surgery. The death resulted from a prescribing error where anaesthetist Dr K. inadvertently prescribed a 100mcg/hou…
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…
78y · Female·multi-organ failure due to haemorrhage into the abdomen, pelvis and retroperiton…
78-year-old Jehovah's Witness died from multi-organ failure secondary to intra-abdominal and retroperitoneal haemorrhage following extensive anterior and posterior lumbar spinal fusion surgery. The patient had multiple c…
43y · Female·acute multiple drug toxicity on a background of chronic pain and morbid obesity
A 43-year-old woman died from acute multiple drug toxicity after 26 years of high-dose opioid therapy for chronic pain following a motor vehicle accident. Despite recognition by multiple clinicians that opioid doses exce…
72y · Male·Metastatic bladder cancer; likely mechanism pulmonary embolism from combined eff…
A 72-year-old male underwent hip replacement despite undiagnosed metastatic bladder cancer. Following referral from his GP in May 2014 for an ultrasound showing bladder wall irregularities suspicious for cancer, urologis…
75y · Female·multiple injuries due to or as a consequence of motor vehicle collision
Ruth Capps, 75, died in a motor vehicle collision after drifting into oncoming traffic. She had multiple medical conditions including diabetes, sleep apnoea, chronic back pain, osteoarthritis, and recurrent falls. Despit…
65y · Male·staphylococcal sepsis (secondary to Staphylococcus aureus infection seeding rect…
A 65-year-old man presented with quad bike accident injuries and had markedly elevated inflammatory markers (CRP 329–556, WCC 12.3–18) during his first hospital admission. These were suggestive of developing infection, p…
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