157 results
74y · Male·Acute myocardial infarction complicated by multiple organ failure
Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…
25y · Male·Combined drug toxicity
Harrison William Ladd, 25, died from combined drug toxicity involving clonazepam, dexamphetamine, codeine, diazepam and pholcodine. He had complex mental health and substance use disorder requiring specialist addiction c…
31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)
A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …
22y · Male·Mixed drug toxicity (tapentadol, clonazepam, citalopram, amphetamine, olanzapine…
Laurence O'Brien, a 22-year-old with acquired brain injury from a childhood motor vehicle accident, died from mixed drug toxicity involving eight substances including prescribed opioids, benzodiazepines, and unprescribed…
48y · Female·Unascertained; presumed sudden cardiac arrhythmia
A 48-year-old woman with cerebral palsy, intellectual disability, and multiple comorbidities died unexpectedly in residential care. Post-mortem examination showed acute pulmonary oedema and intra-alveolar haemorrhage wit…
28y · Male·Multiple head, facial and spinal injuries sustained in a single vehicle motorbik…
Joshua Tyrrell, 28, died from multiple head, facial and spinal injuries sustained in a motorbike crash on the Brooker Highway. He was riding at excessive speed and failed to maintain steering control through a bend. Toxi…
43y · Male·hypoxic brain injury caused by cardiac arrest due to unintentional drug poisonin…
A 43-year-old man with long-standing opioid use disorder and polysubstance dependence died from hypoxic brain injury following cardiac arrest caused by drug poisoning. He had been prescribed large quantities of pregabali…
57y · Female·aspiration of gastric contents caused by combined drug and alcohol toxicity resu…
A 57-year-old woman with complex medical and mental health conditions died from aspiration of gastric contents caused by combined drug and alcohol toxicity. She had severe chronic pain following abdominal surgeries, opio…
54y · Female·mixed drug toxicity (methadone and diazepam)
A 54-year-old woman with long-standing opioid use disorder died from mixed methadone and diazepam toxicity. She had tripled her methadone dose by injecting additional takeaway doses alongside her prescribed pharmacy dose…
39y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to methadon…
A 39-year-old woman with opioid dependency died from methadone toxicity following cardiac arrest. She had been prescribed up to six take-away doses of 120mg methadone per week by her GP under Queensland's Opioid Treatmen…
89y · Female·acute-on-chronic renal failure on a background of ischaemic heart disease, hyper…
An 89-year-old Aboriginal woman with chronic renal impairment and congestive cardiac failure was prescribed gentamicin intramuscularly for a urinary tract infection caused by Klebsiella aerogenes. Gentamicin is nephrotox…
37y · Male·Combined effects of presumed heavy metal poisoning from an unknown material and …
A 37-year-old man with schizophrenia died between 14–18 August 2020 in bushland near Whiteman Creek NSW, from presumed heavy metal poisoning and freshwater drowning. He was experiencing a psychotic episode related to unm…
29y · Male·Mixed drug toxicity (gabapentin, codeine, diazepam, oxycodone, doxylamine, prome…
A 29-year-old man died from mixed drug toxicity involving multiple CNS depressants. His GP, Dr X, had maintained an inappropriate three-year sexual relationship with the patient while prescribing escalating doses of opio…
2y · Male·cardiorespiratory arrest in a young child with opioid (morphine) toxicity
David Flynn, a healthy 2 year 8 month old boy, died from cardiorespiratory arrest due to opioid (morphine) toxicity following an elective circumcision procedure performed under sedation in a general practice setting on 7…
30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…
Heather Calgaret, a 30-year-old Aboriginal woman, died from hypoxic ischaemic encephalopathy after being administered a first dose of buprenorphine (Buvidal) injection without prior stabilisation on sublingual Suboxone. …
60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…
James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…
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…
46y · Male·Respiratory arrest secondary to acute exacerbation of bronchial asthma caused by…
A 46-year-old man with poorly controlled asthma and known ibuprofen hypersensitivity presented to a rural hospital with chest pain. A remote on-call doctor prescribed aspirin without knowledge of the allergy or availabil…
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…
79y · Female·Chronic obstructive pulmonary disease
Jean Alice Dowson, 79, died in an aged care facility after being commenced on end-of-life medications. She had severe COPD and was frail (29kg). On 10 April 2017, when she deteriorated with respiratory distress, a Clinic…
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