22 results
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…
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…
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…
7y · Female·Pneumonia complicating a viral respiratory illness with acute combined drug effe…
Child ML, aged 7, died of pneumonia complicating viral respiratory illness with acute combined drug effect. She had severe cerebral palsy with complex care needs including PEJ tube feeding and multiple medications. At th…
64y · Male·Complications of eosinophilic asthma with bronchiectasis and allergic bronchopul…
Wayne Mullin, a 64-year-old man with severe eosinophilic asthma, bronchiectasis, and allergic bronchopulmonary aspergillosis, died between 21 September and 20 October 2021. Toxicology revealed oxycodone and diazepam at l…
79y · Female·medication related cardiac arrest (verapamil and propranolol) in a patient with …
Mrs Patricia Croxon, a 79-year-old admitted with community-acquired pneumonia, died from medication-related cardiac arrest caused by verapamil and propranolol. The verapamil was charted in immediate release form when she…
57y · Female·Pulmonary thromboembolism
Ann-Maree Manno, 57, died from pulmonary thromboembolism 8 days after laparoscopic gastric band surgery. She had significant risk factors: obesity (BMI 37.9), history of unprovoked DVT in 2007 and 2016, and recent surger…
68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…
Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mi…
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 …
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…
86y · Female·aspiration pneumonia
Viola Diana Clarke, an 86-year-old woman with multiple comorbidities including congestive heart failure, COPD, renal failure, gastric reflux and dysphagia, died from aspiration pneumonia. She was administered incorrect m…
59y · Male·pulmonary thromboemboli due to deep vein thrombosis following right hip replacem…
A 59-year-old man died from pulmonary thromboembolism following right hip replacement surgery. He had mild polycythaemia and elevated BMI (33.26), both risk factors for deep vein thrombosis. Pre-operatively he was classi…
55y · Male·Cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and…
Nigel Douglas Roberts, a 55-year-old man with chronic schizophrenia, COPD, and cardiomyopathy, died from cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and olanzapine) in the presence of adv…
45y · Male·Cardiorespiratory arrest due to coronary artery disease, severe psychosis requir…
Stanley King, a 45-year-old man with severe psychosis, coronary artery disease, and obesity, died from cardiorespiratory arrest triggered by antipsychotic-induced laryngeal dystonia. Admitted involuntarily for acute psyc…
72y · Male·Bilateral pneumothoraces and pneumoperitoneum due to insufflation of the bladder…
Stephen Herczeg, a 72-year-old patient with COPD and urinary tract infection, died from bilateral pneumothoraces and pneumoperitoneum caused by insufflation of his bladder with oxygen. The oxygen supply tubing was someho…
88y · Female·combined effects of an overdose of hydromorphone and complications of pneumonia …
An 88-year-old woman with chronic lung disease, heart disease, and recent pneumonia following faecal transplant for clostridium difficile colitis was prescribed 0.5 mg hydromorphone subcutaneously for respiratory distres…
47y · Male·Bronchopneumonia on a background of methadone and benzodiazepine use
Frank Frood, a 47-year-old man with a 20-year history of heroin use and opioid replacement therapy (ORT) on methadone, died from bronchopneumonia with a background of methadone and benzodiazepine use. He suffered chronic…
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…
85y · Male·Ruptured abdominal aortic aneurysm
An 85-year-old man with known inoperable abdominal aortic aneurysm died from rupture of this aneurysm while hospitalized for acute exacerbation of COPD. A medication error occurred at admission when Dr T. inadvertently i…
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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