65 results
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: (…
87y · Female·right thigh haematoma as a consequence of a periprosthetic fracture of the right…
An 87-year-old woman with multiple comorbidities (diabetes, atrial fibrillation, peripheral vascular disease) sustained a periprosthetic fracture requiring distal femur replacement. She deteriorated significantly during …
26y · Female·Pulmonary thromboembolism due to deep vein thrombosis (left leg) due to fracture…
A 26-year-old woman with a tibia fracture died from pulmonary embolism due to deep vein thrombosis. Despite multiple risk factors (obesity, oral contraceptive use, vaping, leg immobilization, prolonged immobility), no fo…
92y · Male·Consequences of accidental fall at RACF: post-operative delirium, left femoral i…
A 92-year-old man resident in an aged care facility sustained an unwitnessed fall resulting in left hip fracture, requiring surgical fixation. He developed post-operative delirium and died 8 days later. The coroner ident…
86y · Female·Hypostatic pneumonia due to the consequences of a right pubic rami fracture and …
An 86-year-old woman with advanced dementia and frailty suffered an unwitnessed fall at her aged care facility. Initial assessment failed to identify pubic rami and hip fractures. Post-fall documentation was insufficient…
62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…
A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…
66y · Female·Hypoxic-ischaemic encephalopathy
A 66-year-old woman with COPD, obstructive sleep apnoea, and obesity underwent routine knee surgery at Royal Darwin Hospital. Post-operative care was inadequate. Despite dropping oxygen saturations to 88% when sedated an…
74y · Male·small intestinal ischaemia caused by aortic atherosclerosis
A 74-year-old man presented to hospital with abdominal pain following a fall. He developed hypotension, fever, tachycardia, and elevated inflammatory markers consistent with sepsis within hours of admission. Despite clea…
65y · Male·Cardiac arrhythmia, probably Torsades de Pointes, due to the combined effects of…
Linus Phillips, age 65, died at home in October 2014 from cardiac arrhythmia (Torsades de Pointes) precipitated by methadone prescribed with inadequate oversight. Mr Phillips had chronic pain from knee surgery, severe sl…
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…
17y · Male·stroke (left middle cerebral artery infarction) following motorbike collision du…
Kane Mathew Leary, 17, died from a stroke (left middle cerebral artery infarction) following a motorbike collision. The critical clinical lesson involves a missed diagnosis of left internal carotid artery dissection on i…
75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis
A 75-year-old woman with chronic pain and previous staphylococcal infections presented to Glen Innes District Hospital with a swollen, warm right knee 10 days after a corticosteroid injection. Junior doctor Dr M. appropr…
74y · Male·Pulmonary thromboembolism secondary to deep vein thrombosis in the setting of re…
A 74-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis following a cervical spinal fracture. He presented to rural ED with mental health concerns, was restrained by security guards after …
43y · Female·hypoxic brain injury due to pulmonary thromboembolism (right calf deep vein thro…
A 43-year-old woman died of pulmonary embolism following Achilles tendon rupture. She fell in a car park on 4 October 2021, sustaining a right ankle injury initially treated conservatively with immobilisation. An Achille…
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…
70y · Male·hypovolaemic shock due to the consequences of fractured femur
Thomas Fulcher, a 70-year-old man with intellectual disability and osteoporosis in a group home, fell on 19 January 2018 and sustained a spiral femur fracture with internal bleeding. Care workers failed to seek medical a…
20y · Female·multi-organ failure due to polypharmacy overdose
A 20-year-old woman with depression and borderline personality disorder died from multi-organ failure following a large polypharmacy overdose (13 grams of paracetamol among 78 tablets). She was admitted to the ED where i…
54y · Male·Bowel ischaemia resulting from acute thrombosis of superior mesenteric artery an…
Anthony Barrett died from bowel ischaemia caused by acute thrombosis of his superior mesenteric artery and coeliac artery stents post-operatively. He had undergone left total knee replacement surgery at Fairfield Hospita…
52y · Male·Stab injuries to the chest
Mark Edwards, a 52-year-old man, died by suicide via stab injuries to the chest on 11 December 2020. He had suffered a workplace injury in 2007 resulting in amputation of his right leg in 2017, chronic pain, multiple sur…
1y · Female·unrecognised oesophageal intubation
A 19-month-old girl died from unrecognised oesophageal intubation during anaesthesia for finger laceration repair. The anaesthetic team failed to recognise multiple clinical indicators of tube misplacement: absence of pe…
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