49 results
83y · Female·Hyponatraemic encephalopathy due to adverse effects of citaprolam and duloxetine…
An 83-year-old woman with pre-existing SIADH-related chronic hyponatraemia died from hyponatraemic encephalopathy following antidepressant therapy. Critical clinical lessons include: (1) the importance of accessing prior…
73y · Male·Acute intracranial haemorrhage, due to or as a consequence of coagulopathy, due …
Mr Stimpson, a 73-year-old man, died from massive intracerebral haemorrhage secondary to coagulopathy caused by inadvertent double administration of anticoagulants (Clexane and Xarelto). He developed bilateral pulmonary …
83y · Male·pneumonia and severe acute respiratory distress syndrome caused by Legionella ba…
An 83-year-old man died from pneumonia and respiratory distress caused by Legionella bacterium. He presented with abdominal symptoms and was initially misdiagnosed as having aspiration pneumonia rather than community-acq…
33y · Male·Opiate toxicity
A 33-year-old man with previously unrecognized obstructive sleep apnoea was admitted with severe headache. The treating physician prescribed a complex regimen of escalating opiate doses including both slow-release (MS Co…
45y · Female·Combined effects of widely metastatic (end-stage) carcinoma of the cervix and br…
Teressa Maree Beswick, a 45-year-old woman with end-stage metastatic cervical cancer, died from the combined effects of her cancer and bronchopneumonia accelerated by a critical medication error. On 23 October 2014, she …
51y · Male·undetermined natural causes
Chris Prasad, a 51-year-old involuntary psychiatric inpatient with schizoaffective disorder, diabetes type 2, hypertension, and obesity (BMI 30.8), was granted day leave on 17 January 2013 during extreme heat (38°C) at C…
44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)
Jimmy James, a 44-year-old man, died from pneumonia with multiple left-sided rib fractures secondary to a physical assault. He presented to Westmead Hospital ED with clinical signs of septic shock (tachypnoea, hypoxia, h…
32y · Female·massive postpartum intracerebral haemorrhage of spontaneous hypertensive origin
A 32-year-old woman with Factor V Leiden mutation died from a massive postpartum intracerebral haemorrhage of hypertensive origin five hours after delivering twins. She had been diagnosed with pregnancy-induced hypertens…
80y · Female·subdural haematoma due to closed head injury sustained in a fall from bed in hos…
An 80-year-old woman with chronic heart failure admitted to hospital fell from bed and hit her head. Although nursing staff were concerned about a possible head injury, the House Medical Officer incorrectly concluded no …
56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy
A 56-year-old woman presented to Knox Private Hospital with severe headache and eye symptoms on 16 June 2007. An ED physician diagnosed ischaemic stroke based on a subtle CT finding in the absence of focal neurological s…
84y · Female·allergic reaction to metoclopramide (Maxalon) in a woman with acute myocardial i…
An 84-year-old woman with acute myocardial infarction (AMI) and ischaemic bowel died following an allergic reaction to intramuscular metoclopramide (Maxalon) administered by nursing staff without a doctor's order, despit…
66y · Male·multiple organ failure associated with the combined effects of complications of …
Daniel Lahengking, a 66-year-old Indonesian visiting family in Esperance, was diagnosed with rheumatoid arthritis by locum GP Dr H. and prescribed methotrexate 5-10mg daily, a grossly excessive dose (normal: 7.5-20mg wee…
42y · Male·Cardiac arrhythmia secondary to electrolyte imbalance (hyperkalaemia) and verapa…
Glen Kingsun, 42, died from cardiac arrhythmia secondary to electrolyte imbalance and verapamil toxicity. He had complex medical needs requiring multiple specialist and GP care. Critical failures occurred: (1) Medication…
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…
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…
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…
74y · Female·right lower lobe pneumonia (Staphylococcus aureus)
A 74-year-old woman admitted for depression and functional decline following aortic valve replacement received 15mg Nitrazepam instead of prescribed 15mg Mirtazapine due to drug name confusion. The sedation caused aspira…
37y · Male·combined ethanol and drug toxicity
Kenneth Agnew, a 37-year-old man resident in aged care, died from combined ethanol and drug toxicity involving methadone and benzodiazepines. He had hepatitis C and fatty liver disease. Critical clinical lessons include:…
29y · Male·acute bronchopneumonia complicated by multi-drug toxicity
Nicholas Ang, aged 29, with schizoaffective disorder, died from acute bronchopneumonia complicated by multi-drug toxicity while in a psychiatric unit. Admitted 12 August 2005, he was on clozapine, valproic acid, and clon…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.