49 results
Unknown·Lignocaine toxicity following dental surgery with atherosclerotic and valvular h…
George Godden died at Prince of Wales Hospital on 22 February 2007 from lignocaine toxicity following dental surgery. His post-extraction gingival bleeding was treated with gauze soaked in co-phenylcaine spray, a medicat…
32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …
A 32-year-old woman with schizophrenia, well-controlled on clozapine, became pregnant. Poor communication between her general practitioners, community mental health service, and the hospital meant the hospital was unawar…
64y · Male·Large pulmonary embolus (origin undetermined)
Paul Brauer, 64, died of pulmonary embolus at Leeton District Hospital following a complex admission involving psychiatric depression, atrial fibrillation, urinary retention, and multiple comorbidities. The coroner ident…
85y · Male·Ruptured abdominal aortic aneurysm
An 85-year-old man with known inoperable abdominal aortic aneurysm died from rupture of this aneurysm while hospitalized for acute exacerbation of COPD. A medication error occurred at admission when Dr T. inadvertently i…
65y · Male·acute right subdural haematoma
Sidney Brunt, aged 65, died from an acute right subdural haematoma caused by excessive, unmonitored anticoagulation with warfarin. His general practitioner, Dr A., prescribed warfarin for atrial fibrillation but failed t…
40y · Male·respiratory failure due to Adult Respiratory Distress Syndrome (ARDS)
Michael Cockburn, a 40-year-old man with treatment-resistant schizophrenia and documented severe adverse reactions to antipsychotic medications, was admitted to Royal Adelaide Hospital from psychiatric detention for anae…
29y · Female·respiratory depression caused by morphine intoxication on a background of upper …
A 29-year-old woman with infectious mononucleosis and severe sore throat died from respiratory depression caused by morphine intoxication with concurrent upper airway narrowing. A GP administered 30mg intramuscular morph…
74y · Male·cardiac and renal failure complicating treatment of infected ischaemic toes resu…
Glenn Howard Raphael, 74-year-old admitted for infected ischaemic toe secondary to diabetes mellitus. During his 17-day hospital stay, he developed acute renal failure leading to cardiac arrest and death. Critical failur…
35y · Male·pulmonary thromboembolism due to left deep calf vein thrombosis complicating lef…
John Matthew Murray, aged 35, died of pulmonary thromboembolism complicating pelvic and leg fractures sustained in a motorcycle accident. He was admitted to Royal Adelaide Hospital and underwent extensive orthopaedic sur…
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