327 results
45y · Female·Pethidine toxicity
Maree Arthur died from pethidine toxicity at home on 2 February 2008, aged 45. She had complex chronic pain from previous surgeries and motor vehicle injury. Her GP, Dr P., prescribed large quantities of pethidine and ox…
37y · Female·Mixed drug toxicity (methadone, diazepam, clonazepam, amisulpride, olanzapine, h…
Susan Robb, 37, was admitted involuntarily to Northern Hospital Psychiatric Unit with deteriorating mental health and on a Community Treatment Order. Three weeks after self-discontinuing methadone, the treating team re-c…
70y · Female·Aspiration pneumonia, associated with Huntington's disease
Beryl Watson, a severely disabled 70-year-old with advanced Huntington's disease and dementia, died of aspiration pneumonia following a three-week respite stay at a BUPA aged care facility. Critical failures included: om…
92y · Female·Ischaemic heart disease in the setting of inappropriate administration of antihy…
Norma Bensley, a 92-year-old aged care resident, died from ischaemic heart disease after being inadvertently administered another resident's antihypertensive medications. A newly qualified nurse administered the wrong me…
84y · Female·Major cerebral infarct due to hypoglycaemia
Marie Goder, an 84-year-old with diabetes, developed severe hypoglycaemia following insulin administration at a nursing home on 1 November 2009, resulting in prolonged unconsciousness and bilateral cerebral infarcts. Aft…
76y · Female·colchicine toxicity
A 76-year-old woman with gout died from colchicine toxicity after being prescribed 500µg three times daily on 9 December 2010 for an acute attack. She developed diarrhoea from 15 December and died on 19 December with a p…
32y · Male·Multiple drug toxicity (including heroin)
Kirk Steven Ardern, a 32-year-old male with a long history of opioid dependence and substance abuse, died from multiple drug toxicity (including heroin) three days after release from prison. Two critical clinical failure…
33y · Male·toxic effects of oxycodone
A 33-year-old man died from oxycodone toxicity after his general practitioner prescribed escalating doses of the opioid for intermittent migraines over 14 months (5-30mg daily), despite a prior rejection of a pethidine a…
67y · Female·Lithium toxicity with chest infection and bipolar disorder; Alzheimer's disease …
Mrs Snopek, aged 67 with bipolar disorder on long-term lithium, was prescribed coversyl (an ACE inhibitor) by Dr A. in January 2008 for hypertension. This combination is contraindicated as ACE inhibitors impair renal fun…
66y · Male·Intracerebral haemorrhage
A 66-year-old man with intracerebral haemorrhage and concurrent deep vein thrombosis died following an accidental tenfold heparin overdose. The patient received 20,000 units instead of 2,000 units due to a nurse misreadi…
38y · Male·Heart failure in a man with dilated cardiomyopathy and focal severe coronary art…
Anthony Axtell, a 38-year-old man with severe dilated cardiomyopathy from amphetamine use, died of heart failure while in prison custody. Initially treated successfully in 2002 with recovery to normal cardiac function by…
19y · Female·combined drug effect and myocarditis
A 19-year-old Aboriginal woman with alcohol and cannabis abuse died at Graylands Hospital from combined drug effect and myocarditis. Following two suicide attempts within 48 hours, she was sedated and transferred via Roy…
74y · Female·Cardio-renal failure due to gangrene of calculous gallbladder, with significant …
An elderly woman with a documented penicillin allergy, wearing a MedicAlert bracelet, presented to emergency with respiratory distress and chest pain. She was administered intravenous Ampicillin without allergy verificat…
68y · Female·Anaphylaxis in a woman with atherosclerotic cardiovascular disease and emphysema
A 68-year-old woman with severe COPD and undiagnosed atherosclerotic heart disease underwent cataract surgery at Northam Hospital. Post-operatively, she was prescribed Diamox (acetazolamide), a sulphonamide medication. D…
87y · Female·heart failure and probable pneumonia in an elderly lady complicated by morphine …
An 87-year-old woman with dementia, heart disease, and hypertension presented with chest pain and hypoxia. A locum doctor (Dr B.) administered 20mg morphine intramuscularly without reviewing the patient's notes, medical …
28y · Male·Overdose of Clozapine
A 28-year-old man with schizophrenia and substance abuse history died from clozapine overdose. Key clinical failures included: inadequate assessment of suicide risk when prescribing one month's supply to a patient presen…
38y · Male·mixed drug toxicity and arrhythmogenic right ventricular dysplasia
Shane Andrew Kromwyk, aged 38, died at home on 14 March 2009 while on home detention bail. Post-mortem examination revealed mixed drug toxicity (methadone, diazepam, alprazolam) combined with pre-existing arrhythmogenic …
68y · Male·Dilated cardiomyopathy with previous aortic valve replacement and aortic graft
A 68-year-old man with aortic valve replacement died from undiagnosed dilated cardiomyopathy, with retroperitoneal haemorrhage as a contributing factor. He developed a large perinephric haematoma (1900mL) secondary to ov…
72y · Female·Intrathecal toxicity of bupivacaine and morphine
A 72-year-old woman with terminal metastatic parotid cancer died from intrathecal toxicity of bupivacaine and morphine. She was admitted to Ashford Hospital for pain management of pathological pelvic fractures. An intrat…
33y · Male·Cardio-respiratory arrest in the setting of prone restraint of an agitated obese…
A 33-year-old man with schizophrenia and a forensic history suffered cardio-respiratory arrest during prone restraint in a busy emergency department after his mental health community treatment order was revoked. He was a…
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