16y · Female·consequences of acute asthma with hypoxic encephalopathy
Jessica-Lee Dennis, aged 16, died from acute asthma with hypoxic encephalopathy on 7 May 2004. She presented with progressive nocturnal cough and wheezing over six weeks starting September 2001, with significant family h…
29y · Female·respiratory depression caused by morphine intoxication on a background of upper …
A 29-year-old woman with infectious mononucleosis and severe sore throat died from respiratory depression caused by morphine intoxication with concurrent upper airway narrowing. A GP administered 30mg intramuscular morph…
24y · Male·0.22 calibre gunshot wound to the head (self-inflicted)
Christopher Merritt, a 24-year-old man with a history of reactive depression triggered by relationship breakdowns, presented to his GP Dr. Watson on 30 June 2003 with acute tearfulness, suicidal ideation, and dangerous r…
67y · Female·Pneumonia (streptococcus pneumoniae) in a woman receiving treatment for carcinom…
Peggy Anne Nilon, 67, died from pneumonia (streptococcus pneumoniae) at St John of God Hospital Bunbury on 25 February 2003. Her small cell lung cancer had achieved remission following chemotherapy and radiotherapy. A cr…
24y · Female·multi organ failure due to meningococcal septicaemia
24-year-old woman presented to ED with fever (40.1°C), headache, myalgia and mild photophobia. RMO Dr R., relatively inexperienced (5 weeks in Australia), examined her thoroughly but focused on excluding meningitis throu…
55y · Female·Multiple drug toxicity due to combination of alcohol and benzodiazepines (oxazep…
Carol Anne Kiley, a 55-year-old woman with chronic back pain, depression, and likely alcohol dependence, died from multiple drug toxicity involving alcohol, oxazepam (toxic level), temazepam, and promethazine. Her GP, Dr…
31y · Male·hanging (self-inflicted)
Darryl Walker, a 31-year-old Aboriginal man with chronic schizophrenia and diabetes, died by hanging in Port Lincoln Prison on 2 June 2003. He had been transferred to an isolated management unit (Unit 7) on 1 June after …
20y · Male·Pelvic Injury
Peter Daryl Samson, a 20-year-old Aboriginal male, died from a pelvic fracture sustained in a motor vehicle rollover on 22 September 2003. He was brought to Derby Regional Hospital where he was assessed briefly by nursin…
20y · Male·hanging
A 20-year-old male with major depressive disorder and melancholic features was admitted to psychiatric hospital on 4 June 2003 under an indefinite involuntary treatment order by consultant psychiatrist Dr P.. The next da…
72y · Female·Peritonitis due to perforated diverticulum in transverse colon
Maria Donatelli, a 72-year-old woman with cardiac and renal disease, presented to Peel Health Campus with abdominal pain and vomiting. She was initially managed conservatively with a provisional diagnosis of pancreatitis…
35y · Male·Disseminated Lymphoblastic Lymphoma
A 35-year-old Aboriginal man died from disseminated lymphoblastic lymphoma while in prison custody. He presented with progressive symptoms including oedema, shortness of breath, and difficulty walking. Dr J. appropriatel…
69y · Female·faecal peritonitis due to small bowel obstruction and perforation due to periton…
A 69-year-old woman presented to the Emergency Department with abdominal pain and vomiting. The doctor did not take adequate history, perform thorough physical examination, or order basic investigations including blood t…
45y · Male·bronchopneumonia and suppurative bronchitis complicating hypoxic brain damage
Ian McLeod, a 45-year-old lawyer with alcohol dependence and depression, died from hypoxic brain damage and bronchopneumonia following a hanging while in custody at Yatala Labour Prison. Multiple system failures contribu…
35y · Male·Acute Staphylococcus aureus Meningitis
Christopher Nigel Spinks, a 35-year-old tree surgeon, died of acute Staphylococcus aureus meningitis on 3 December 2002. He initially presented on 27 November 2002 with neck pain following a windsurfing accident. Dr R. n…
31y · Male·Pulmonary thromboembolism arising from deep vein thrombosis
Adam David McKay, a 31-year-old geologist, died from pulmonary thromboembolism arising from deep vein thrombosis on 23 January 2003. He had recently completed extensive long-haul flights to West Africa and returned on 13…
67y · Female·perforated gastric ulcer; morphine toxicity also made a significant contribution
Mrs Lillian Shaw, a 67-year-old obese woman with a history of NSAID use, presented with vomiting and abdominal pain over 36 hours. A GP visited three times without performing adequate physical examination, failed to insp…
26y · Female·morphine toxicity complicated terminally by bronchopneumonia
A 26-year-old woman with chronic migraines and depression died from morphine toxicity complicated by aspiration pneumonia. She had a documented history of drug-seeking behaviour, forged prescriptions, and doctor-shopping…
43y · Male·aspiration of vegetable matter with occlusion of the upper airway
Peter Cornish, a 43-year-old man with a 17-year history of bipolar disorder, died on 25 September 2001 from aspiration of vegetable matter while experiencing a severe manic episode. In the two weeks before his death, mul…
25y · Male·cerebral craniopharyngioma
Gregory Andrew Furniss, a 25-year-old male with a history of asthma and congenital cataracts, presented to Swan District Hospital on 11 August 2002 with a persistent headache. He was seen by Dr H. (registrar) who diagnos…
41y · Male·haemorrhage due to incised wounds to left and right cubital fossae
Jeffrey Ronald Fredericks, aged 41, died in Adelaide Remand Centre custody from haemorrhage due to self-inflicted incised wounds to both cubital fossae. Critical clinical lessons: screening tools identified significant s…
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