338 results
32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity
A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with …
60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…
James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…
Male·heroin overdose
This is a procedural decision (not final inquest findings) regarding Felipe Esteban Alvarez's heroin-related death in March 2021. Approximately 4 hours elapsed between his overdose at a residential unit and the emergency…
42y · Male·Multiple organ failure due to iatrogenic phenol overdose due to metastatic pancr…
A 42-year-old man with metastatic pancreatic cancer died from multiple organ failure caused by iatrogenic phenol overdose during a celiac plexus block for pain management. The radiologist administered 40ml of 80% phenol …
71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation …
A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxon…
75y · Female·Ischaemic heart disease in the setting of unstable type 2 diabetes mellitus and …
Veronica Roberts, 75, died from ischaemic heart disease complicated by unstable diabetes and a medication error. On 4 October 2020, her insulin dose was increased to 20 units daily, but due to Electronic Medical Record (…
43y · Male·Hypoxic ischaemic encephalopathy, due to or as consequence of, cardiac arrest of…
A 43-year-old man with methamphetamine toxicity was restrained by police and given two doses of droperidol by paramedics who failed to recognize he was critically unwell. The first dose was clinically indicated, but the …
86y · Female·Pulmonary thromboembolism in the setting of deep leg vein thrombosis, secondary …
Barbara Deal, 86, died from pulmonary embolism secondary to deep vein thrombosis 17 days after lumbar spinal fusion surgery. Critical failures included: no repeat VTE risk assessments despite policy requirements; inconsi…
74y · Female·Infective exacerbation of chronic obstructive airways disease in the setting of …
Caroline McCormack, 74, died from infective exacerbation of chronic obstructive airways disease following a medication administration error where pregabalin was erroneously included in her Webster-pak despite being cease…
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…
46y · Male·Respiratory arrest secondary to acute exacerbation of bronchial asthma caused by…
A 46-year-old man with poorly controlled asthma and known ibuprofen hypersensitivity presented to a rural hospital with chest pain. A remote on-call doctor prescribed aspirin without knowledge of the allergy or availabil…
47y · Female·Mixed drug toxicity (venlafaxine, duloxetine, mirtazapine, oxycodone, tapentadol…
Kim Bartolo, a 47-year-old woman with depression, anxiety, alcohol use disorder and chronic conditions, died from mixed drug toxicity involving multiple prescription medications. She was admitted to Brunswick Private Hos…
79y · Male·Respiratory failure due to haemothorax and hospital-acquired pneumonia due to mu…
A 79-year-old man with extensive comorbidities died following multiple falls in residential aged care. He was identified as high falls risk on admission but experienced inadequate falls prevention after a second fall on …
43y · Male·Amitriptyline toxicity
Scott Alan Murdoch, a 43-year-old maximum-security prisoner with chronic suicidal ideation, borderline personality disorder, and a documented history of medication hoarding and overdose attempts, died from amitriptyline …
79y · Female·Chronic obstructive pulmonary disease
Jean Alice Dowson, 79, died in an aged care facility after being commenced on end-of-life medications. She had severe COPD and was frail (29kg). On 10 April 2017, when she deteriorated with respiratory distress, a Clinic…
71y · Male·raised intracranial pressure caused by left frontal-temporal-parietal subdural h…
Warren James Newell, a 71-year-old man with oesophageal cancer, presented with acute coronary syndrome on 29 September 2022 and was appropriately diagnosed and treated with anticoagulation and dual antiplatelet therapy. …
89y · Male·Complications in association with a gastrointestinal illness in an elderly man w…
Raymond Sydney Cheek, an 89-year-old prisoner with multiple comorbidities including insulin-dependent diabetes, died from complications of gastrointestinal illness with acute renal failure. While medical care at Casuarin…
73y · Female·Multi organ failure due to adhesions related bowel perforation (surgically treat…
Sharyn Kaine, a 73-year-old woman, died from multi-organ failure due to adhesions-related bowel perforation and paracetamol-induced liver failure. She was prescribed intravenous paracetamol 1g four times daily post-opera…
87y · Male·Combined effects of sotalol toxicity on a background of severe valvular and athe…
An 87-year-old man with Alzheimer's disease died in a residential aged care facility after ingesting Sotalol, a cardiac medication not prescribed to him. The medication trolley was left unlocked and accessible despite fa…
84y · Female·Complications associated with Diabetes Mellitus (likely hyperosmolar hyperglycae…
Mrs Charlotte Paluszak, 84, died at a residential aged care facility after rapid deterioration from complex dementia and diabetes. On 10 November 2017, she developed acute semiconsciousness and agitation. The clinical nu…
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