88 results
74y · Female·Cardio-renal failure due to gangrene of calculous gallbladder, with significant …
An elderly woman with a documented penicillin allergy, wearing a MedicAlert bracelet, presented to emergency with respiratory distress and chest pain. She was administered intravenous Ampicillin without allergy verificat…
33y · Male·Cardio-respiratory arrest in the setting of prone restraint of an agitated obese…
A 33-year-old man with schizophrenia and a forensic history suffered cardio-respiratory arrest during prone restraint in a busy emergency department after his mental health community treatment order was revoked. He was a…
69y · Female·Septic shock due to biliary peritonitis as a consequence of laparoscopic cholecy…
A 69-year-old woman died of septic shock following bile leak complications after laparoscopic cholecystectomy. Critical failures included: (1) inappropriate transfer to low-dependency unit on post-op day 1 despite consul…
34y · Female·hypoxic ischaemic encephalopathy due to anaphylactic shock due to antibiotic all…
A 34-year-old woman died from anaphylactic shock to Ceclor, a cephalosporin antibiotic prescribed for otitis externa. Her medical records clearly documented allergies to cephalosporins (Ibilex) and sulphur-based antibiot…
49y · Male·pneumonia, hypoxic brain injury and cardiac arrest
49-year-old male with chronic cannabis dependence and depression developed post-surgical delirium following emergency anterior resection for perforated diverticulum. He became acutely agitated and paranoid, was detained …
Three deaths with different primary causes: James Unicomb - acute toxicity due t…
Combined inquest into three deaths at Psyche South Clinic involving treatment failures: James Unicomb (22, 2005) from multi-drug overdose after naltrexone implant; Michael Poole (48, 2008) from ruptured aneurysm post-Rap…
50y · Male·Complications of right buttock necrotising fasciitis secondary to chronic right …
50-year-old male with chronic pain from jockey injuries became dependent on morphine. General practitioner prescribed intramuscular (IM) morphine for self-administration at home from 2005–2007 at doses of 120–240mg daily…
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·Respiratory arrest in association with medication drug effect and alcohol intoxi…
David James Lee, a 37-year-old Aboriginal man with schizophrenia, died on 15 July 2007 at Port Hedland Regional Hospital from respiratory arrest associated with medication effect and alcohol intoxication. He arrived at t…
45y · Male·Hypoxic-ischaemic encephalopathy due to prolonged hypoxia
A 45-year-old man died from hypoxic-ischaemic encephalopathy following cardiopulmonary arrest 11 hours after elective wrist plate removal surgery. Multiple contributing factors were identified: undisclosed obstructive sl…
17y · Male·pneumonia and respiratory failure associated with choreoathetoid cerebral palsy
A 17-year-old Indigenous male with severe choreoathetoid cerebral palsy, feeding difficulties, and swallowing dysfunction died of pneumonia and respiratory failure in ICU. He had missed lunch medications (Baclofen and Ga…
28y · Male·hypoxic brain injury sustained during restraint in the foyer of the Acute Mental…
Lyji Vaggs, a 28-year-old Aboriginal man with schizophrenia, died from hypoxic brain injury sustained during restraint at Townsville Hospital's Acute Mental Health Unit on 13 April 2010. He had declined admission at ED o…
34y · Female·Catastrophic post-partum haemorrhage following caesarean delivery, secondary to …
A 34-year-old Vietnamese woman died from catastrophic postpartum haemorrhage following an elective caesarean delivery. Placenta accreta was discovered intraoperatively and managed with blood transfusion, uterotonic agent…
81y · Female·Severe cardiogenic shock complicating cardiac surgery
An 81-year-old woman died of severe cardiogenic shock following elective aortic valve replacement complicated by intraoperative haemodynamic instability and inadequate postoperative ICU management. The surgery involved e…
39y · Male·rhabdomyolysis complicating cocaine toxicity against a background of atheroscler…
A 39-year-old man with undiagnosed atherosclerotic coronary artery disease died from rhabdomyolysis complicating cocaine toxicity. He exhibited cocaine-induced excited delirium with erratic dangerous driving and bizarre …
39y · Female·heart failure connected to a massive pulmonary embolus as a result of deep vein …
A 39-year-old woman died from acute heart failure due to massive pulmonary embolus from deep vein thrombosis two days after laparoscopic appendicectomy. She presented to ED with abdominal pain and nausea, was diagnosed w…
29y · Female·Invasive aspergillosis
A 29-year-old registered nurse with systemic lupus erythematosus (SLE) died from invasive aspergillosis. Dr G. prescribed lamotrigine 100 mg daily (double the recommended initial dose of 50 mg) on first consultation with…
81y · Female·hypovolaemic shock following bleeding from the site of a femoral angiogram
Olga Krivitch, 81-year-old woman, died from hypovolaemic shock caused by bleeding from her femoral angiogram puncture site. She was admitted for ischaemic leg and underwent unsuccessful thrombolytic therapy. Subsequently…
83y · Female·Congestive cardiac failure due to ischaemic and valvular heart disease
An 83-year-old woman with Down syndrome and cardiac disease died from congestive cardiac failure at Royal Adelaide Hospital following accidental medication administration error in a community group home. On 1 July 2007, …
82y · Female·Complications from hypoglycaemic brain damage and cerebral vascular accident
Margaret Allan Johnston, 82-year-old admitted for UTI and confusion, was found comatose on 4 September 2006 with severe hypoglycaemia (glucose 0.8 mmol/L) despite being non-diabetic. Blood tests revealed high insulin and…
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