113 results
8y · Female·Aspiration pneumonia in a child with an epileptic encephalopathy and extreme cac…
HB, age 8 years 10 months, died from aspiration pneumonia with extreme cachexia (BMI 7). She had severe cerebral palsy, epilepsy (Lennox-Gastaut syndrome), and was entirely dependent on PEG tube feeding. Between January …
74y · Female·Subdural haemorrhage following a fall in a woman with multiple medical comorbidi…
Mrs Chettle, a 74-year-old aged care resident with multiple comorbidities including dementia, schizoaffective disorder, and a nine-fall history in twelve months, fell from a shower chair while a personal care assistant b…
20y · Male·massive basal subarachnoid haemorrhage caused by a blow to the head
A 20-year-old man died in 1971 from a subarachnoid haemorrhage that was initially attributed to spontaneous rupture of a cerebral artery aneurysm. An inquest 45 years later, based on neuropathological expert evidence, fo…
22y · Male·Multiple injuries from fall from height
Mitchell Follent, 22, died by fall from a third-floor balcony five days after discharge from his first psychiatric admission for post-ictal/drug-induced psychosis. He had intellectual disability, epilepsy, and acquired b…
20y · Male·sudden unexplained death in epilepsy (SUDEP); right frontal lobe epidermal cyst …
A 20-year-old man with a history of seizures and a previously resected frontal lobe cyst presented to hospital with severe headaches. Despite his significant medical history of epilepsy and prior neurosurgery, he was dis…
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…
15y · Male·Multiple organ failure associated with hyperthermia (heat stroke)
A 15-year-old rugby league player died from heat stroke during training on an extremely hot Perth summer evening (44.4°C). The coaching staff appropriately applied NRL heat guidelines in deciding to proceed with modified…
53y · Male·fentanyl and oxycodone toxicity
Stephen Robert Atkins, 53, died from fentanyl and oxycodone toxicity after admission to Flinders Medical Centre for investigation of Horner's syndrome and radiculopathy. Over three days, escalating opioid doses were pres…
72y · Female·Obstruction of the airways of the neck
A 72-year-old woman with moderate-severe expressive and receptive dysphasia following an acute left middle cerebral artery stroke died by hanging three months post-discharge from rehabilitation. Critical deficiencies wer…
63y · Female·disseminated metastatic carcinoma of unknown primary in a woman with multiple sc…
Pamella Rees, a 63-year-old woman with longstanding multiple sclerosis, died on 30 June 2014 from disseminated metastatic carcinoma of unknown primary. Her cancer went undiagnosed despite regular GP contact. In her final…
0y · Male·complications of head injury
A premature newborn died from severe head injuries inflicted deliberately by his teenage father in hospital on 15 February 2014. The father had a well-documented history of violence, substance abuse, criminality and had …
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 …
Unknown·acute fentanyl toxicity; acute oxycodone toxicity; multiple drug toxicity; opioi…
Four adults died from opioid overdoses (fentanyl and oxycodone) in Queensland between 2012–2014. All obtained prescriptions from multiple doctors ('doctor shopping') without effective detection. Systemic failures include…
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…
57y · Male·large volume ischaemic infarct (stroke)
Stephen John French, a 57-year-old with prior stroke (2002) and myocardial infarction (2009), presented with headache, visual disturbance and gait difficulty in May 2013. Imaging at Launceston General Hospital on 30 May …
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…
41y · Female·Left middle cerebral artery territory ischaemic stroke
A 41-year-old registered nurse presented to the Emergency Department with altered consciousness on 28 May 2015. She was initially assessed as having a possible medication overdose rather than acute stroke, despite later …
78y · Female·Complications of a left tentorial meningioma
A 78-year-old woman with a meningioma detected incidentally on MRI in 2009 presented to hospital in 2015 with gait disturbance and falls. The tumour had grown significantly, causing hydrocephalus and mass effect. After a…
0y · Female·Group B Streptococcus meningitis and sepsis
An 18-day-old baby died from late-onset Group B Streptococcus (GBS) meningitis and sepsis. She was born at a regional private hospital after labour complicated by maternal fever (37.6°C), foetal tachycardia (160-170 bpm)…
46y · Female·Prolonged effects and complications of a head injury, with upper airway obstruct…
Helen Ashburn, a 46-year-old woman with history of alcohol use, coagulopathy and seizures, died from prolonged effects of a severe head injury sustained on 25 October 2011. She presented to Kempsey Hospital with extensiv…
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