113 results
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures
Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…
35y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to vertebro…
A 35-year-old woman presented to a rural hospital with a three-day history of collapses, slurred speech, vomiting, and abnormal eye movements. A non-contrast CT head scan was normal, and she was discharged with a diagnos…
47y · Male·unascertained
Eric Donald Brandrick, a 47-year-old man with significant disability from a right thalamic intracerebral haemorrhage stroke in September 1988, was last confirmed alive on 31 December 1989 at Royal Perth Hospital Emergenc…
57y · Female·Multi-organ failure due to drug-induced liver injury caused by sodium valproate …
Mrs Doherty, a 57-year-old woman with CADASIL syndrome, was prescribed sodium valproate for migraine prophylaxis in November 2019. She developed acute hepatitis approximately 5 months later, presenting with jaundice, nau…
0y · Female·Unascertained
A 9-month-old girl died suddenly on 23 July 2018 following multiple head injuries from blunt force trauma sustained shortly before death. She had presented to medical practitioners multiple times in the preceding weeks w…
69y · Male·thoracic aortic aneurysm with dissection
Peter Hanisch, a 69-year-old man, died from thoracic aortic aneurysm with dissection on 22 August 2021. He presented to Calvary Hospital on 19 August 2021 with sudden chest discomfort and neurological symptoms. A CT angi…
15y · Male·multiple injuries caused by a motor vehicle accident
Kailab Moir, a 15-year-old Aboriginal boy with FASD, complex trauma, and ADHD, died in a single-vehicle rollover while a passenger in a stolen vehicle. He had been in out-of-home care since age 5 with approximately 35 di…
22y · Male·ligature compression of the neck (hanging)
Ricky-Lee Cound, a 22-year-old Noongar man with Foetal Alcohol Spectrum Disorder (FASD), died by suicide in Hakea Prison on 25 March 2022 from ligature compression. Critical clinical lessons emerge: (1) his FASD diagnosi…
20y · Male·Drowning precipitated by a seizure
Cameron De Vries, a 20-year-old man with severe autism spectrum disorder and global developmental delay, died by drowning precipitated by a seizure in a bathtub at a disability support home. He had experienced a seizure …
43y · Female·Severe diffuse hypoxic brain injury caused by administration of supratherapeutic…
A 43-year-old woman died from severe diffuse hypoxic brain injury caused by excessive sodium bicarbonate administration during treatment of amitriptyline overdose. The treating ED consultant prescribed sodium bicarbonate…
55y · Male·Diabetic ketoacidosis
CM, a 55-year-old man with severe congenital disabilities and Type 2 Diabetes, died from diabetic ketoacidosis while residing in a disability support facility. In the week preceding death, he experienced reduced appetite…
45y · Female·Multiple blunt force injuries
A 45-year-old woman with acute psychotic illness attended Prince of Wales Hospital ED on 4 August 2020 after presenting to police with persecutory delusions. She was assessed by mental health and medical clinicians who a…
48y · Female·Hypoxic ischaemic encephalopathy due to pulmonary thromboembolism due to deep ve…
A 48-year-old woman with morbid obesity and smoking history presented to a rural hospital with severe hip and leg pain. Over five days across two hospitals, no venous thromboembolism (VTE) risk assessment was performed d…
92y · Female·Consequences of an assault
A 92-year-old woman with dementia died from consequences of an assault by another resident with unmanaged psychosis in an aged care facility. The assault occurred after the facility failed to adequately monitor, assess, …
37y · Male·Sudden unexpected death in epilepsy (SUDEP) in the setting of acquired brain inj…
Kieran McGuinness, 37, died of sudden unexpected death in epilepsy (SUDEP) following acquired brain injury with post-traumatic epilepsy. He was found unresponsive on his apartment floor on 11 September 2022, having been …
81y · Male·Head injury sustained in a fall
Michele Valentino, 81, died from a head injury sustained in a fall on 20 December 2019, with death occurring on 24 December 2019. A CT angiogram at 3:45pm showed worsening intraventricular haemorrhage (IVH) that was not …
85y · Male·Intracranial haemorrhage in the setting of a fall in a man with multiple comorbi…
An 85-year-old man with multiple comorbidities suffered a fall at home and was transported to hospital with stroke symptoms. A CT brain scan revealed subtle subarachnoid haemorrhage (traumatic), but the VST consultant ne…
73y · Male·Combined effects of cerebrovascular accident and subsequent iatrogenic related i…
A 73-year-old man presented to ED with acute facial droop and speech difficulty on 5 September 2020. He was misdiagnosed with Bell's palsy despite clinical features suggestive of stroke. A non-contrast CT brain (inadequa…
34y · Female·Multi drug toxicity
Jodie Overstead, a 34-year-old with epilepsy, anxiety, and chronic pain, died from multi-drug toxicity involving tramadol, codeine, amitriptyline, benzodiazepines and other drugs. She engaged in 'doctor shopping', obtain…
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