52 results
51y · Female·Chest sepsis in the setting of recurrent aspiration pneumonia, cerebral palsy, L…
Danielle Noonan, aged 51, died from chest sepsis secondary to recurrent aspiration pneumonia. She had severe disability including cerebral palsy, Lennox-Gastaut syndrome, spastic quadriplegia, and intellectual disability…
67y · Female·Pulmonary thrombo-embolism secondary to deep venous thrombosis, with contributin…
Vicki Grigg, 67, died from pulmonary embolism three days after discharge from Goulburn Valley Health. She had been admitted with influenza A exacerbating asthma and COPD, and received standard-dose anticoagulation prophy…
70y · Male·Multiple organ failure secondary to bronchopneumonia and acute pancreatitis in a…
Philip Arnott, a 70-year-old man with schizophrenia, died from multiple organ failure secondary to bronchopneumonia and acute pancreatitis. He had taken the maximum recommended dose of paliperidone since 2015. Between Ja…
86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall
James Reilly, 86, fell at home on 8 September 2024 sustaining rib fractures that caused a fatal left haemothorax. Paramedics attended but he declined transfer. When facial droop developed, he was admitted with presumed t…
41y · Male·acute, severe hydrocephalus contributed to by longstanding chronic hydrocephalus…
Benjamin Cullen, aged 41, died on 25 February 2021 from acute severe hydrocephalus secondary to a brain tumour abutting the cerebral aqueduct. He suffered three seizures on 23 February 2021, two days after release from P…
90y · Female·Right acute on chronic subdural haematoma sustained in a fall in the setting of …
A 90-year-old woman on warfarin for atrial fibrillation suffered an unwitnessed fall with head strike at an aged care facility. She presented to hospital where a small subdural haemorrhage was not detected on initial CT …
42y · Female·Pneumonia, underlying severe cerebral palsy
Rachel Piskun, aged 42, died from pneumonia complicated by severe cerebral palsy. She had severe disabilities requiring 24-hour care in supported accommodation. During a September 2021 hospitalization, compression stocki…
57y · Female·Multi-organ failure due to drug-induced liver injury caused by sodium valproate …
Mrs Doherty, a 57-year-old woman with CADASIL syndrome, was prescribed sodium valproate for migraine prophylaxis in November 2019. She developed acute hepatitis approximately 5 months later, presenting with jaundice, nau…
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 …
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 (…
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…
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…
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…
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.…
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…
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 · 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…
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…
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…
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 …
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