94 results
55y · Male·Complications of right middle cerebral artery infarction
Simon Mark Everill, a 55-year-old man with intellectual disability and epilepsy, suffered a right middle cerebral artery infarction on 3 September 2014 after experiencing two falls during a day service activity. His symp…
38y · Male·cardiac arrest precipitated by dilutional hyponatraemia
A 38-year-old construction worker died from dilutional hyponatraemia after working in extreme heat (>40°C) on a concrete formwork project in rural Queensland. He developed symptoms of heat injury at the worksite and was …
36y · Female·Global ischaemic injury following cardiorespiratory arrest in the immediate post…
Caroline Lovell, 36, died from postpartum haemorrhage following home birth of her second child. She had significant risk factors: prior PPH with first child and uterine fibroid, but these were not properly investigated b…
55y · Male·Cardiac tamponade due to ruptured aortic dissection (Type A) against a backgroun…
Rick Dickinson, a 55-year-old man, presented to St Andrew's War Memorial Hospital after experiencing severe central chest pain and lower back pain with numbness at the gym. The treating senior doctor failed to adequately…
60y · Male·medication overdose
Bruce Andrews, a 60-year-old man with major depression and anxiety, died from medication overdose following relationship breakdown and acute alcohol intoxication. He fell from his porch, called his granddaughter reportin…
47y · Male·Toxic effects of phosphine gas
Jeremy Harding-Roots died from phosphine gas toxicity after deliberately exposing himself to the pesticide fumigant aluminium phosphide (Fumitoxin) during a siege at his former girlfriend's residence. Key clinical and pr…
0y · Male·Head injury from non-accidental trauma (forced shaking) occurring on 11 May 2009
Baby R, born at 28 weeks gestation, died of non-accidental head injury sustained on 11 May 2009 when forcefully shaken by a person or persons unknown while in parental care. The 5-month-old presented with cardiorespirato…
4y · Male·Severe rhabdomyolysis due to LPIN1 gene mutation
Tom Olive, aged 4, died from severe rhabdomyolysis caused by a rare LPIN1 gene mutation. Over 12 months before death, he presented with recurrent episodes of dark urine, muscle pain, and lethargy. Multiple GPs and a paed…
74y · Female·haemothorax secondary to dissecting thoracic aorta
Mrs Petzierides, a 74-year-old woman, presented to the emergency department with sudden-onset, severe left scapular pain radiating to the jaw, occurring shortly after midnight. She was assessed by an emergency medicine r…
29y · Male·Bronchopneumonia complicating neck injuries sustained in a fall, with Coffin-Low…
A 29-year-old man with Coffin-Lowry Syndrome suffered a severe cervical spinal cord injury from a fall at a respite facility. Disability workers found him on the floor but initially interpreted his presentation as non-co…
0y · Male·Complications of small bowel obstruction due to post operative adhesions
Marcus Charles, a 3-month-old neonate, died from small bowel obstruction due to postoperative adhesions following earlier surgical repair of oesophageal atresia and duodenal atresia. On 4 November 2006, paramedics attend…
Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…
Two obese patients died from hypoxic-ischaemic encephalopathy following cardio-respiratory deterioration post-operatively at a private hospital without overnight medical cover. John Ryan (54) deteriorated within hours of…
76y · Female·hospital acquired pneumonia, multiple organ dysfunction and small bowel obstruct…
Mrs Cook, a 76-year-old woman, died in January 2010 from hospital-acquired pneumonia, multiple organ dysfunction, and small bowel obstruction. She was admitted to a rural hospital with acute renal failure and dangerously…
46y · Female·Multiple injuries sustained in collision between semi-trailer and train; tension…
On 5 June 2007, a semi-trailer collided with a V/Line passenger train at Kerang level crossing in Victoria, killing 11 train passengers immediately and one more (Harold Long) during transfer. The driver (Mr Scholl) faile…
32y · Male·Multiple injuries sustained when struck by semi-trailer at level crossing
In 2007, a semi-trailer collided with a V/Line train at the Kerang level crossing in regional Victoria, killing 11 train passengers. The driver, Christian Scholl, did not see the flashing red-filtered incandescent lights…
50y · Male·Multiple injuries sustained in collision between semi-trailer and train
A comprehensive coronial investigation into 26 deaths from 12 level crossing collisions in Victoria (2002-2009), with particular focus on the Kerang incident (5 June 2007) in which 11 train passengers died when a semi-tr…
79y · Female·multiple injuries sustained in collision between semi-trailer and train
On 5 June 2007, a semi-trailer collided with a V/Line passenger train at the Kerang level crossing, killing 11 train passengers. The driver had traversed this crossing many times in seven years without seeing a train, an…
17y · Female·Acute Methylenedioxymethylamphetamine (MDMA) toxicity
Gemma Thoms, a 17-year-old girl, died from acute MDMA toxicity after consuming three ecstasy tablets at the Big Day Out music festival on 1 February 2009. She collapsed and died on 2 February 2009. Key clinical lessons: …
50y · Male·Global hypoxic brain injury suffered during cardiac and respiratory arrest cause…
Herbert Mitchell, a 50-year-old man with alcohol dependence, was arrested for public drunkenness after being found extremely intoxicated at a shopping centre. Initially taken to an alcohol diversion centre but removed du…
55y · Male·Morphine toxicity, with contributing factors of ischemic heart disease, coronary…
Shane Paul Krog, a 55-year-old man, died from morphine toxicity complicated by ischemic heart disease, coronary atherosclerosis and rhabdomyolysis. He presented to Murgon Hospital (a 15-bed rural facility) following susp…
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