43y · Female·sepsis secondary to extensive acute peritonitis following perforation of small b…
43-year-old woman died from sepsis and necrotising fasciitis following small bowel perforation during laparoscopic tubal ligation. She was at high risk due to previous abdominal surgeries and adhesions. A 4-5mm perforati…
27y · Female·Aspiration of gastric contents associated with persistent vomiting following gas…
A 27-year-old woman died from aspiration of gastric contents following a vertical-banded gastroplasty performed for morbid obesity. The surgeon created a stoma (opening) of 4-5mm diameter using a 27 French bougie, smalle…
26y · Male·neck compression due to hanging
A 26-year-old Aboriginal man with longstanding borderline personality disorder, substance abuse, and multiple suicide attempts died by hanging in a psychiatric ward whilst detained under a Mental Health Act order. Key cl…
19y · Male·heroin toxicity
Marshall Carter, 19, died in custody from heroin toxicity at Yatala Labour Prison. He had a long history of drug abuse starting from age 14 and was an intravenous heroin user. Critical failures included: inadequate trans…
37y · Male·Traumatic intracranial haemorrhages/brain damage and fractured skull
A 37-year-old male died from traumatic intracranial haemorrhage and skull fracture after being punched and falling onto concrete. The critical clinical lesson is that head injuries may be completely undetectable on exter…
54y · Male·respiratory failure and acute renal failure due to rhabdomyolysis following trau…
A 54-year-old man with chronic schizophrenia and intellectual disability died from respiratory failure and acute renal failure secondary to rhabdomyolysis following a crush injury to his left thigh sustained while attemp…
47y · Male·Ligature compression of the neck (hanging)
Kenneth John Groth, aged 47, died by hanging in Casuarina Prison on 9 April 1998. He was a sentenced prisoner convicted of sexual offences, serving a 10-year sentence. His appeal was adjourned and legal aid was refused, …
23y · Male·aspiration of blood due to stab wound to trachea
23-year-old man with self-inflicted stab wound to neck presenting to emergency department while intoxicated and agitated. Ambulance noted 3cm laceration to midline trachea with minimal external bleeding. Registered nurse…
12y · Female·Head injury caused by high-velocity steel fragment missile, approximately 999 gr…
Katie Bender, aged 12, was struck fatally in the head by a 999-gram steel fragment while watching the controlled implosion of Royal Canberra Hospital on 13 July 1997. The fragment travelled 430 metres in 3.1 seconds at 1…
14y · Male·Loss of blood arising from incised wound to the left arm (cubital fossa)
A 14-year-old Aboriginal petrol sniffer brought to a remote outstation (Ilpurla) without pre-arrangement died from massive haemorrhage following a self-inflicted laceration to his arm. Clinical lessons: petrol sniffers i…
0y · Male·multi-organ failure from septicaemia following surgical reduction of intussuscep…
Nathan Wrench, 11 weeks old, presented to Queanbeyan Hospital on 14 October 1996 with persistent vomiting for 3 days. GP Dr R. diagnosed viral infection with possible reflux, admitted for observation, and managed conserv…
69y · Female·Asthma
June Sylvia Long, aged 69, suffered an asthma attack at home on 28 June 1994 and was transported to Alfred Hospital. She deteriorated overnight in the hospital's Respiratory Ward despite initial improvement in Emergency …
3y · Male·cerebral oedema which caused coning at the base of the brain, caused by post-ope…
A 3-year-old boy died from cerebral oedema caused by post-operative hyponatraemia following scoliosis correction surgery. The operation was successful, but severe hyponatraemia developed in the early hours of 24 April 19…
20y · Male·Retro-peritoneal and intra-peritoneal haemorrhage due to perforation of the left…
A 20-year-old Aboriginal man died from retroperitoneal and intra-peritoneal haemorrhage caused by perforation of the left internal iliac artery from a gunshot wound to the abdomen, inflicted by Constable Lawrence John Cl…
87y · Male·acute renal failure and two major haemorrhagic strokes
An 87-year-old man with multiple comorbidities including previous strokes, atrial fibrillation, and diabetes died from acute renal failure and two major haemorrhagic strokes after three months in an aged care facility. D…
85y · Female·Sepsis relating to an infected right shoulder wound (including MRSA)
Ellen Plymin, aged 85, sustained a fractured humerus in a fall and underwent surgical fixation at Western Hospital on 10 May 2007. She returned to Westgate Aged Care Facility post-operatively on 14 May. By 28 May, wound …
0y · Female·Subdural and subarachnoid haemorrhages due to late onset vitamin K deficiency bl…
A 33-day-old exclusively breastfed baby died from subdural and subarachnoid haemorrhages caused by late-onset vitamin K deficiency bleeding (VKDB). The parents, exercising informed choice based on spiritual beliefs, decl…
24y · Male·Aspiration pneumonia secondary to drug abuse and overdose of multiple drugs
A 24-year-old man with schizophrenia died from aspiration pneumonia following overdose of multiple drugs including diazepam, tramadol, morphine, and others. The day before death, he took excess diazepam to manage auditor…
66y · Male·Complications of chronic lithium therapy
Sydney Kennedy, a 66-year-old man with intellectual disability and bipolar affective disorder, died from complications of chronic lithium therapy. He had been on lithium for years with annual psychiatric review, but ther…
83y · Female·Complications following fracture and surgical repair of the left hip in an elder…
Mrs Nola Inez Daniel, an 83-year-old with chronic lung disease, osteoporosis, and cardiac disease, was admitted to Regis Forrest Gardens for respite care on 24 December 2009. She sustained three falls on Christmas Day, w…
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