88 results
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…
28y · Male·Brain death due to large right acute subdural haematoma sustained as a result of…
David Browne died from brain death due to a subdural haematoma sustained during a professional boxing match on 11 September 2015. The coroner found the death was preventable. Critical failures occurred: the referee did n…
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…
75y · Male·left retroperitoneal haemorrhage associated with lumbar spine surgery
A 75-year-old man with complex comorbidities including Parkinson's disease and cognitive impairment underwent two-stage lumbar spine surgery for degenerative disc disease with stenosis. Post-operatively, he developed a r…
62y · Female·subacute subdural haematoma due to a closed head injury sustained in a fall from…
A 62-year-old woman on warfarin for a mechanical aortic valve sustained a head injury from a fall. A CT scan on day 5 post-injury identified a small extradural haematoma, but the radiologist (Dr J.) failed to report it, …
23y · Female·chronic hydrocephalus with brain swelling
A 23-year-old registered nurse with undiagnosed chronic hydrocephalus presented to the ED with neck pain, headache and vomiting. Dr B. assessed her briefly without formal examination or detailed history, prescribed ketor…
75y · Male·acute right subdural haemorrhage sustained in a fall
George Triantafilopoulos, a 75-year-old man on warfarin after aortic valve replacement, suffered two head strikes within 24 hours—first falling onto concrete at a supermarket on 14 August 2014, then falling onto concrete…
41y · Male·Subdural haematoma
A 41-year-old Aboriginal man with excessive alcohol use presented four times to a rural hospital over one month with headaches. His symptoms were attributed to cluster migraine, then alcohol withdrawal syndrome, despite …
77y · Female·Subdural haematoma secondary to blunt head trauma (head-strike)
A 77-year-old woman on warfarin for atrial fibrillation presented to Sandringham Hospital after striking her head on a wall. Despite being on anticoagulation therapy, no CT scan was performed, and she was discharged afte…
53y · Male·Bilateral ACA stroke
A 53-year-old man presented to the emergency department with acute stroke symptoms (left-sided hemiplegia and dysphasia) with onset around 10:30 am. Due to fluctuating symptoms and delays in stroke team referral, he was …
60y · Female·Complications of metastatic melanoma in the setting of neck of femur fracture fo…
Susan Ruth Lovell, a 60-year-old woman, died from complications of metastatic melanoma in the setting of a neck of femur fracture sustained during a fall. A skin lesion on her left calf, noted in January 2010, was clinic…
32y · Female·massive postpartum intracerebral haemorrhage of spontaneous hypertensive origin
A 32-year-old woman with Factor V Leiden mutation died from a massive postpartum intracerebral haemorrhage of hypertensive origin five hours after delivering twins. She had been diagnosed with pregnancy-induced hypertens…
31y · Female·raised intracranial pressure due to ventriculoperitoneal shunt dysfunction (disc…
Emilie Le Coz, aged 31, died from raised intracranial pressure secondary to ventriculoperitoneal shunt disconnection. She presented to hospital in March 2010 with progressive headaches, cognitive changes and behaviour de…
80y · Female·subdural haematoma due to closed head injury sustained in a fall from bed in hos…
An 80-year-old woman with chronic heart failure admitted to hospital fell from bed and hit her head. Although nursing staff were concerned about a possible head injury, the House Medical Officer incorrectly concluded no …
56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy
A 56-year-old woman presented to Knox Private Hospital with severe headache and eye symptoms on 16 June 2007. An ED physician diagnosed ischaemic stroke based on a subtle CT finding in the absence of focal neurological s…
57y · Male·Head injury from fall; with coronary atherosclerosis and complete heart block wi…
A 57-year-old man with bipolar disorder died from head injury following a fall at Toowong Private Hospital. Critical failures in falls risk management were identified: no formal falls risk assessment was completed on adm…
69y · Male·Intracerebral haemorrhage due to sepsis (Staphylococcus aureus bacteraemia), com…
A 69-year-old man with a history of myocardial infarction and atrial fibrillation presented to a rural hospital with fever, lethargy, tachycardia and elevated troponin. The treating doctor diagnosed NSTEMI based on the e…
39y · Female·Hypoxic brain injury secondary to multiple hypovolaemic cardiac arrests from cat…
Linda Parker, aged 39, died from hypoxic brain injury following catastrophic postpartum haemorrhage from placenta increta during caesarean delivery. Critical lessons: (1) Placenta increta risk was not detected prenatally…
72y · Female·Hanging
Chang Ying Xu, a 72-year-old Chinese-speaking woman with severe spinal cord compression, chronic pain, and depression, died by hanging during respite care at an aged care facility. While her depression history and multip…
3y · Male·Brainstem ischaemia in association with Arnold Chiari malformation
Matthew Whyte, a 3-year-old with Arnold Chiari malformation and hydrocephalus, died from brainstem ischaemia following multiple shunt complications and emergency decompression surgery. The coroner found that after Matthe…
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