19 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 …
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…
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…
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…
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…
86y · Female·Pulmonary thromboembolism in the setting of deep leg vein thrombosis, secondary …
Barbara Deal, 86, died from pulmonary embolism secondary to deep vein thrombosis 17 days after lumbar spinal fusion surgery. Critical failures included: no repeat VTE risk assessments despite policy requirements; inconsi…
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…
51y · Male·Multiple organ failure due to Influenza A pneumonia, in the context of chronic k…
Ishmael Nalaiyir Nangarid, a 51-year-old Aboriginal man with complex medical history including myasthenia gravis, chronic kidney disease, COPD, and ischaemic heart disease, died from multiple organ failure due to Influen…
66y · Male·Aspiration pneumonia complicating a seizure in a man with dysphagia and phenylke…
A 66-year-old man with phenylketonuria and intellectual disability died from aspiration pneumonia complicated by seizure following missed anti-epileptic medications at his residential care facility. He presented to St Vi…
83y · Male·pneumonia and severe acute respiratory distress syndrome caused by Legionella ba…
An 83-year-old man died from pneumonia and respiratory distress caused by Legionella bacterium. He presented with abdominal symptoms and was initially misdiagnosed as having aspiration pneumonia rather than community-acq…
44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)
Jimmy James, a 44-year-old man, died from pneumonia with multiple left-sided rib fractures secondary to a physical assault. He presented to Westmead Hospital ED with clinical signs of septic shock (tachypnoea, hypoxia, h…
69y · Female·Inadvertent intravenous administration of oral ciprofloxacin in the setting of a…
A 69-year-old woman with stroke, diabetes, atrial fibrillation and osteomyelitis died from inadvertent intravenous administration of crushed oral ciprofloxacin. The antibiotic was prescribed for the nasogastric tube but …
69y · Male·Intracerebral haemorrhage due to sepsis (Staphylococcus aureus bacteraemia), com…
A 69-year-old man with a history of myocardial infarction and atrial fibrillation presented to a rural hospital with fever, lethargy, tachycardia and elevated troponin. The treating doctor diagnosed NSTEMI based on the e…
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…
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…
90y · Female·Renal failure secondary to gentamicin therapy for urinary tract infection (sepsi…
Ellen O'Connor, a 90-year-old woman with renal artery stenosis and coronary artery disease, died from acute renal failure following gentamicin administration for Pseudomonas aeruginosa urinary tract infection. A single 2…
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…
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…
54y · Female·sepsis
Ms Julie Stephens, aged 54, was admitted to Frankston Hospital on 5 December 2008 with a chest infection and multiple comorbidities including cardiac failure, respiratory failure, and obesity. She deteriorated with septi…
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