94 results
68y · Female·Sepsis (Enterobacter cloacae) due to peritonitis as a consequence of leaking per…
A 68-year-old woman with oculopharyngeal muscular dystrophy died from sepsis due to peritonitis following dislodgement of a PEG tube inserted on 27 February 2018. She presented to a rural hospital 5.5 hours post-discharg…
81y · Female·Complications of choking on a food bolus in a woman with dementia
Dorothy May Nelson, an 81-year-old woman with dementia, died from complications of choking on a food bolus at an aged care facility. She was served diced beef in casserole (approximately 4cm bolus found at autopsy, despi…
71y · Female·pneumonia following cervical spine fracture sustained in motor vehicle collision
Julie Anne Holmes, aged 71, died of pneumonia following a cervical spine fracture sustained in a motor vehicle accident that was not diagnosed during her hospital admission. Critical clinical lessons include: (1) paramed…
63y · Male·complications of an inverted positional event (asphyxia from airway occlusion)
A 63-year-old man with previous stroke and left-sided paralysis fell headfirst into his bedside drawer while attempting to open it from his motorised wheelchair. He became trapped with his airway occluded. An enrolled nu…
17y · Male·Diabetic ketoacidosis
Caleb Pearson, a 17-year-old with undiagnosed Type 1 diabetes, presented with pharyngitis and was diagnosed and treated for a throat infection by his GP on 25 May 2015. Over the following two days he deteriorated with vo…
33y · Male·cardiorespiratory arrest during restraint, involving a predisposition to cardiac…
33-year-old Indigenous man died following police restraint and inappropriate midazolam administration during an acute drug-induced behavioural disturbance. Mr Coolwell sustained injuries while in acute methamphetamine-in…
50y · Male·Hypoxic-ischaemic encephalopathy secondary to choking on food bolus
A 50-year-old man with acquired brain injury and intellectual disability died from hypoxic-ischaemic encephalopathy following aspiration of a food bolus during lunch at his disability care residence. The carer appropriat…
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…
29y · Male·acute asthma
A 29-year-old male with known asthma and hay fever died from acute asthma during the November 2016 thunderstorm asthma event in Melbourne. He presented to Ballarat Hospital on 21 November with severe asthma, was treated …
35y · Female·Pulmonary thromboembolus and pulmonary infarction
A 35-year-old woman at 11 weeks gestation presented to Royal Women's Hospital Emergency Care on 3 September 2012 with chest and rib pain following severe vomiting. Dr M., a junior resident working alone overnight, assess…
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…
54y · Male·Ischaemic cardiomyopathy following a period of restraint on a background of morb…
A 54-year-old man with schizophrenia, homelessness, and morbid obesity was arrested for wilful exposure and disorderly conduct. During restraint in the prone position with handcuffs, he struggled for several minutes. Alt…
64y · Male·Septic shock secondary to urosepsis (Pseudomonas and Stenotropomonas maltophilia…
RD, a 64-year-old man with diabetes, amputation, and COPD, presented to a private hospital emergency department with suspected sepsis (vomiting, diarrhoea, hypotension, acute kidney injury, elevated troponin, hyperkalaem…
49y · Male·ischaemic heart disease with coronary artery thrombosis (left main stem coronary…
Wayne Mitchell, a 49-year-old man, presented to a clinic with acute chest pain radiating to his jaw, accompanied by dizziness, diaphoresis, and dyspnoea. His symptoms resolved before ambulance arrival. The paramedics per…
28y · Female·ligature compression of the neck
Mary Van Der Walt, a 28-year-old with depression, anxiety, and borderline personality disorder, died by hanging on 21 April 2014. Two police officers responding to her initial '000' call found her unresponsive and pulsel…
45y · Male·gunshot wound to the chest
A man with a long history of depression, suicide attempts, and previous violent behaviour died when shot by police during an arrest for domestic violence. His partner had repeatedly warned police that he threatened to ma…
45y · Female·multiple organ failure following thermal injuries (severe burns)
Wendy Bearfoot, a 45-year-old DEC (Department of Environment and Conservation) employee, died from multiple organ failure following severe thermal burns (80% of body) sustained in a bushfire burnover on 12 October 2012. …
29y · Female·peritonitis caused by ischaemia of the bowel due to gastrointestinal torsion (tw…
Shona Hookey, a 29-year-old Aboriginal woman with severe intellectual disability and aphasia, died of peritonitis secondary to bowel torsion. Critical failures occurred at multiple levels: carers at her group home delaye…
0y · Male·Complications of hypoxic ischaemic encephalopathy secondary to recurrent episode…
Kyran Day, a 6-month-old boy, presented to Shoalhaven District Memorial Hospital with vomiting and lethargy on 19 October 2013. He was initially assessed and diagnosed with gastroenteritis based on recent rotavirus vacci…
34y · Male·sepsis due to extensive small bowel infarct caused by bowel incarceration within…
Jason Keith Harrison, aged 34, died from sepsis due to extensive small bowel infarction caused by bowel incarceration within a congenital mesenteric hernia. He presented to West Coast District Hospital with epigastric pa…
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