326 results
73y · Male·Complications of metastatic neuroendocrine lung carcinoma
John O'Donnell, aged 73, died in custody from complications of metastatic neuroendocrine lung cancer while hospitalised at Westmead Hospital. The coroner identified two systemic issues during his brief incarceration at S…
64y · Male·Complications of eosinophilic asthma with bronchiectasis and allergic bronchopul…
Wayne Mullin, a 64-year-old man with severe eosinophilic asthma, bronchiectasis, and allergic bronchopulmonary aspergillosis, died between 21 September and 20 October 2021. Toxicology revealed oxycodone and diazepam at l…
32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome
Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included…
81y · Female·Subdural haemorrhage from fall with exacerbation by anticoagulant therapy
An 81-year-old woman with atrial fibrillation and Alzheimer's disease fell at home on 21 December 2020, sustaining a subdural haematoma. Nambour Hospital appropriately ceased her anticoagulant (rivaroxaban) and planned c…
46y · Male·Opioid toxicity (tapentadol and oxycodone)
Bradley Liefvoort, 46, died from opioid toxicity (tapentadol and oxycodone) at home in Dandenong. Over a decade of prescription medication misuse began with ibuprofen for headaches, escalating to opioid dependence follow…
34y · Female·Multi drug toxicity
Jodie Overstead, a 34-year-old with epilepsy, anxiety, and chronic pain, died from multi-drug toxicity involving tramadol, codeine, amitriptyline, benzodiazepines and other drugs. She engaged in 'doctor shopping', obtain…
91y · Male·Complications of cerebrovascular and ischaemic heart disease in a man post anaph…
A 91-year-old man with known diltiazem allergy was prescribed diltiazem by a geriatrician despite documented allergy records. The geriatrician relied on the patient's verbal denial of allergies despite significant dement…
87y · Female·Complications following a medication administration error in a woman with multip…
An 87-year-old woman died from complications of a medication administration error at an aged care facility. During transition from paper-based to electronic medication charts in December 2020, a pharmacy data entry error…
86y · Male·progressive cognitive decline/decompensation and gastrointestinal haemorrhage
An 86-year-old man with Parkinson's disease and long-standing gastro-oesophageal reflux disease (GORD) sustained a traumatic brain injury from a fall at home on 3 July 2021. He was admitted to hospital on 6 July 2021 wit…
79y · Female·medication related cardiac arrest (verapamil and propranolol) in a patient with …
Mrs Patricia Croxon, a 79-year-old admitted with community-acquired pneumonia, died from medication-related cardiac arrest caused by verapamil and propranolol. The verapamil was charted in immediate release form when she…
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
Maarouf El-Cheikh, a 57-year-old man with splenectomy history, presented to Calvary Hospital ED with sepsis on 21 March 2016 and died 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadeq…
70y · Male·Coronary atherosclerosis
Mirko Civic, a 70-year-old prisoner with a significant cardiac history including prior myocardial infarction, hypertension, and ischaemic heart disease, died of coronary atherosclerosis in September 2018. Critical clinic…
76y · Male·Chest sepsis in a man with ischaemic heart disease
A 76-year-old man with multiple myeloma and complex medical history died from chest sepsis and myocardial infarction following a medication dispensing error. After discharge from hospital for spinal compression fractures…
80y · Female·Anaphylaxis complicating chemotherapy for the treatment of metastatic fallopian …
Ms Heather Jean Lucas, 80-year-old woman with metastatic fallopian tube cancer, died from anaphylaxis during her third carboplatin chemotherapy infusion. She had experienced a documented Grade 2 hypersensitivity reaction…
92y · Female·Clozapine toxicity in a lady with terminal lung carcinoma
A 92-year-old woman with terminal lung cancer died from clozapine toxicity after receiving medication intended for another resident. An Enrolled Nurse preparing the medication trolley inadvertently placed another residen…
76y · Male·Small bowel obstruction and acute renal failure, due to or as a consequence of m…
Adrian Adams, aged 76, died in Princess Alexandra Hospital from small bowel obstruction and acute renal failure secondary to metastatic colorectal cancer. He was serving an eight-year sentence for sexual offences at the …
81y · Male·cardiac arrest following neck compression due to hanging
An 81-year-old man with a history of alcohol dependence, paranoid delusions regarding his wife's infidelity, and possible vascular dementia was admitted to mental health facilities involuntarily after discharging a firea…
42y · Male·Complications post polypharmacy toxicity
Gregory Sedgman, aged 42, died from polypharmacy toxicity after consuming excessive prescription medications at a post-sentence supervision residential facility. He had deliberately accumulated medications despite a seiz…
47y · Female·Mixed drug toxicity (pregabalin, oxycodone and mirtazapine)
A 47-year-old woman died from mixed drug toxicity involving pregabalin, oxycodone, and mirtazapine. She had chronic pain, anxiety, and depression, and attended a medical clinic frequently. Over five days before her death…
73y · Male·Haemorrhagic stroke in the setting of recent inguinal hernia surgery and change …
Paul Turner, 73-year-old with atrial fibrillation and aortic valve replacement, underwent elective bilateral inguinal hernia repair in August 2018. His cardiologist advised ceasing rivaroxaban 3-4 days preoperatively; ho…
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