32 results
89y · Female·acute-on-chronic renal failure on a background of ischaemic heart disease, hyper…
An 89-year-old Aboriginal woman with chronic renal impairment and congestive cardiac failure was prescribed gentamicin intramuscularly for a urinary tract infection caused by Klebsiella aerogenes. Gentamicin is nephrotox…
67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…
Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pa…
81y · Male·Community acquired pneumonia in a man with acute on chronic renal failure
An 81-year-old man with chronic respiratory disease and renal failure died from community-acquired pneumonia complicated by acute-on-chronic renal failure. He presented to hospital on 25 April 2023 with respiratory failu…
51y · Male·complications of myocardial infarction in association with ischaemic heart disea…
A 51-year-old prisoner died from complications of myocardial infarction with ischaemic heart disease. He had multiple cardiovascular risk factors including type-2 diabetes, hypertension, high cholesterol, chronic kidney …
83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)
An 83-year-old male prisoner died from complications of a ruptured abdominal aortic aneurysm (AAA) after a 5-month delay in diagnostic confirmation and treatment. An incidental finding of an 8.7 cm AAA was identified on …
32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome
Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included…
64y · Male·Complications of metformin toxicity on a background of undiagnosed renal impairm…
Peter Gretton, a 64-year-old man imprisoned at Junee Correctional Centre, died from metformin toxicity complicated by acute renal impairment and severe lactic acidosis. His renal function deteriorated in the three to fou…
74y · Male·Intra-abdominal haemorrhage complicating elective umbilical hernia repair
A 74-year-old man with significant cardiac history (atrial fibrillation, dilated cardiomyopathy, pacemaker) underwent elective umbilical hernia repair. Intraoperatively, unexpected ascites was discovered and partially dr…
75y · Male·multifactorial causes on a background of ischaemic heart disease, generalised va…
Robert Bischard, a 75-year-old man with multiple complex comorbidities including coronary artery disease, chronic kidney disease, and diabetes, died five days after elective right total knee replacement surgery. The coro…
58y · Female·Enterococcus faecalis sepsis and acute renal failure
Robena Lloyd, a 58-year-old woman with intellectual disability and schizophrenia, died from enterococcus faecalis sepsis and acute renal failure on 7 August 2009. She presented to Angliss Hospital ED on 31 July with urin…
59y · Male·ischaemic heart disease in the context of acute-on-chronic kidney failure associ…
Arthur James Bonney, a 59-year-old prisoner with advanced cardiac disease, chronic kidney disease, and diabetes, underwent a CT scan with iodinated contrast on 30 July 2015 at Fiona Stanley Hospital. Critical failures oc…
55y · Male·probable sepsis in the setting of immunosuppression, a skin wound and chronic di…
David Paul Unwin, a 55-year-old kidney transplant recipient with polycystic kidney disease, died of sepsis in January 2017. He presented with progressive symptoms including chronic diarrhoea, weight loss (16kg in 8 weeks…
77y · Male·Complications of methotrexate toxicity in a man with chronic renal impairment, c…
A 77-year-old man with chronic kidney disease, COPD, and mild cardiac failure died from methotrexate toxicity after a GP prescribed it at an inappropriate daily dose (5mg daily) for psoriasis without baseline blood tests…
71y · Male·cardiac arrest due to hyperkalemia due to acute on chronic renal failure, with r…
John Bell, a 71-year-old man with history of bowel cancer, ischaemic heart disease, and chronic renal failure, underwent elective ileostomy reversal surgery. He died from cardiac arrest due to hyperkalemia and metabolic …
86y · Male·Aspiration Pneumonia secondary to Recurrent Colorectal Carcinoma
An 86-year-old man died from aspiration pneumonia following bowel preparation for elective colonoscopy. He was admitted to an outlying ward rather than the gastroenterology unit, where nursing staff documented multiple e…
59y · Female·Multiorgan failure and polymicrobial sepsis secondary to severe bone marrow fail…
A 59-year-old woman with renal transplant died from multiorgan failure and sepsis secondary to severe bone marrow failure caused by azathioprine toxicity. She had an undiagnosed genetic polymorphism (TPMT *3A/*3A homozyg…
57y · Female·Haemothorax following acute thoracic aortic dissection in a woman with congenita…
Sally Hopwood, 57, with Turner syndrome, coarctation of the aorta, and bicuspid aortic valve, presented to ED on 23 March 2012 with severe acute back and chest pain (8/10). A chest X-ray revealed widened mediastinum. She…
75y · Female·pyelonephritis and pneumonia
Molly Jessie Smith, a 75-year-old woman with longstanding severe mental illness, died of pyelonephritis and pneumonia on 16 August 2009. She had been in state psychiatric care continuously for 53 years. During her final …
76y · Female·Acute renal failure due to dehydration due to upper gastrointestinal bleed
A 76-year-old woman with chronic pain was admitted to a small rural hospital on 1 April 2015 with haematemesis secondary to NSAID use. Blood tests were ordered on admission but not transported to the district hospital fo…
73y · Female·Multiple organ failure due to or as a consequence of sepsis due to or as a conse…
73-year-old woman died 12 days after elective colorectal surgery for synchronous caecal and rectal tumours. Post-operatively, she developed persistent low urine output and intermittent hypotension managed with repeated f…
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