326 results
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…
81y · Male·Carcinoid tumour (metastasis) / metastatic cancer
Donald Richard Gunthorpe, an 81-year-old man with metastatic rectal carcinoma, was appropriately transitioned to end-of-life (palliative) care at a residential aged care facility after hospitalisation for abdominal pain.…
70y · Female·Heart failure due to paroxysmal atrial fibrillation treated with flecainide card…
A 70-year-old woman with complex cardiac history including heart failure, paroxysmal atrial fibrillation, and coronary atherosclerosis presented with urinary tract infection and atrial fibrillation on Christmas Day 2021.…
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…
David Edwards: disseminated lymphomatosis complicating large B-cell lymphoma. Ne…
David Edwards, aged 90, died of disseminated lymphomatosis (advanced lymphoma) on 2 March 2016. His death was natural and expected given his terminal illness. His wife Nelda Edwards, aged 88, died two days later on 4 Mar…
81y · Male·Chronic lung disease (severe COPD) with atherosclerotic cardiovascular and valvu…
An 81-year-old man with severe COPD died following inappropriate interhospital transfer to a private hospital and subsequent management errors. Key clinical lessons: (1) patients with CO2 retention require explicit ident…
73y · Female·fractured neck of femur (operated) on a background of Alzheimer's dementia
Linda Eileen Saberton, aged 73, died from complications of a fractured neck of femur sustained in a fall at her aged care facility, on a background of advanced Alzheimer's dementia. She had suffered two hip fractures wit…
36y · Male·Undetermined; three possible mechanisms identified: oversedation with vomiting a…
Jacob Kennedy, a 36-year-old Aboriginal man with polysubstance use disorder and psychiatric illness, died on 4 February 2017 after 11 days as an involuntary inpatient at Frankston Hospital. He was administered multiple s…
16y · Male·mixed drug toxicity (codeine, morphine, tramadol, alprazolam and desmethylvenlaf…
LI, a 16-year-old with borderline personality disorder, factitious disorder, and opioid use disorder, died from mixed drug toxicity (codeine, morphine, tramadol, alprazolam, desmethylvenlafaxine) after obtaining prescrip…
2y · Male·multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndro…
A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poo…
7y · Female·Pneumonia complicating a viral respiratory illness with acute combined drug effe…
Child ML, aged 7, died of pneumonia complicating viral respiratory illness with acute combined drug effect. She had severe cerebral palsy with complex care needs including PEJ tube feeding and multiple medications. At th…
61y · Male·congestive cardiac failure due to cardiomegaly with left ventricular hypertrophy
A 61-year-old man with diabetes, obesity, and high cholesterol presented to his GP with shortness of breath for 4-5 days and tachycardia (HR 120). The GP diagnosed anxiety instead of cardiac failure, failed to ask critic…
29y · Male·Methadone toxicity
Darren James Fielding died in custody at Middleton Prison on 26 May 2018 from methadone toxicity. He was on day 6 of opioid substitution therapy (OSTP) when he received his prescribed 10mg methadone dose. Expert evidence…
36y · Female·Stab wound to the right chest
Amanda Jane Harris, 36, was fatally stabbed by her intimate partner Daniel Eckersley on 7 July 2018 in Cranbourne North, Victoria. Eckersley was prescribed high-dose tramadol (700-800mg daily) for chronic pain over 22 mo…
82y · Female·traumatic closed head injury (subdural haematoma) resulting from a fall from sta…
Mrs Emily Jones, 82, died from subdural haematoma following an unwitnessed fall at Royal Hobart Hospital on 15 November 2021. She was admitted five days after discharge from Hobart Private Hospital where she was treated …
86y · Female·Bradycardic arrest secondary to relative hypoperfusion while undergoing surgery …
An 86-year-old woman underwent elective surgery to excise a probable squamous cell carcinoma from her left hand with split-thickness skin grafting under local anaesthesia with intravenous sedation. She suffered an unexpe…
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