39 results
85y · Male·Sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left …
An 85-year-old man died in custody from sepsis due to Staphylococcus aureus bacteraemia arising from septic arthritis of the left shoulder, on a background of congestive heart failure. While receiving generally adequate …
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 …
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…
71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation …
A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxon…
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 (…
79y · Male·Respiratory failure due to haemothorax and hospital-acquired pneumonia due to mu…
A 79-year-old man with extensive comorbidities died following multiple falls in residential aged care. He was identified as high falls risk on admission but experienced inadequate falls prevention after a second fall on …
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…
87y · Male·Combined effects of sotalol toxicity on a background of severe valvular and athe…
An 87-year-old man with Alzheimer's disease died in a residential aged care facility after ingesting Sotalol, a cardiac medication not prescribed to him. The medication trolley was left unlocked and accessible despite fa…
84y · Female·Complications associated with Diabetes Mellitus (likely hyperosmolar hyperglycae…
Mrs Charlotte Paluszak, 84, died at a residential aged care facility after rapid deterioration from complex dementia and diabetes. On 10 November 2017, she developed acute semiconsciousness and agitation. The clinical nu…
81y · Male·Carcinoid tumour (metastasis) / metastatic cancer
Donald Richard Gunthorpe, an 81-year-old man with metastatic rectal carcinoma, was appropriately transitioned to end-of-life (palliative) care at a residential aged care facility after hospitalisation for abdominal pain.…
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…
73y · Female·fractured neck of femur (operated) on a background of Alzheimer's dementia
Linda Eileen Saberton, aged 73, died from complications of a fractured neck of femur sustained in a fall at her aged care facility, on a background of advanced Alzheimer's dementia. She had suffered two hip fractures wit…
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…
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…
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…
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…
79y · Male·myocardial infarction
Brian Davies, 79, died of myocardial infarction while under an Inpatient Treatment Order for Alzheimer's dementia at Noarlunga Hospital. He presented with cognitive decline following his partner's death and developed agi…
61y · Male·Pneumonia
A 61-year-old man with significant medical complexity including acquired brain injury, bronchiectasis, pulmonary fibrosis, and dysphagia died from pneumonia 26 days after receiving another resident's slow-release opioid …
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