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NSWhospital2024-04-12

Inquest into the death of Everett Carleton

0y · Male·multifactorial with severe hypoxia/hypotension which occurred in the background …

Everett Carleton died at birth following an emergency caesarean section complicated by unexpected placenta praevia and umbilical cord transection. The placenta was incorrectly reported as posterior on ultrasound, though …

obstetricsneonatologycommunicationprocedural
WAhospital2023-05-22

Inquest into the Death of Errol Warren BARTLETT

87y · Male·Metastatic carcinoma of the prostate with complications (end-of-life palliative …

Errol Warren Bartlett-Torr, aged 87, died of metastatic prostate cancer on 20 June 2021 whilst in prison custody and receiving palliative care at Bethesda Hospital. Clinical lessons include: (1) elevated PSA findings sho…

oncologypalliative carecommunicationsystemwarfarin
WAhospital2023-04-17

Inquest into the Death of Edward Ivan AFRICH

64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …

Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart fai…

respiratory medicinecardiologycommunicationsystemthiamine
NSWhospital2020-01-31

Inquest into the death of OS

5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …

A five-year-old child with complex neurodevelopmental conditions and polypharmacy (including valproic acid for epilepsy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with ora…

plastic and reconstructive surgeryanaesthesiamedicationproceduralmorphine
QLDhospital2017-10-17

SWK - Non inquest findings

78y · Female·multi-organ failure due to haemorrhage into the abdomen, pelvis and retroperiton…

78-year-old Jehovah's Witness died from multi-organ failure secondary to intra-abdominal and retroperitoneal haemorrhage following extensive anterior and posterior lumbar spinal fusion surgery. The patient had multiple c…

spinal surgeryorthopaedic surgeryproceduraldiagnosticaramine
VIChospital2015-12-02

Finding into death of Khodr El Mustapha

77y · Male·Complications of reaction to an iron infusion in a man with ischaemic heart dise…

A 77-year-old man with iron deficiency anaemia and underlying ischaemic heart disease died from anaphylaxis following iron polymaltose infusion. Critical clinical lessons: (1) IV iron should only be administered after or…

emergency medicinehaematologydiagnosticproceduraliron polymaltose
SAhospital2005-01-18

Coroner's Finding: SQUIRES Dorothy Alberta

90y · Female·incompatible blood transfusion resulting in haemolysis and multi-organ failure c…

A 90-year-old woman with acute myocardial infarction and cardiogenic shock died after receiving an incompatible blood transfusion (A- instead of O+), which caused haemolysis and multi-organ failure. The registered nurse …

cardiologyintensive careproceduralcommunication
SAhospital2003-03-12

Coroner's Finding: STOLL Ruth Sophie

71y · Female·massive acute haemolysis leading to severe anaemia and multi-system failure as a…

Ruth Stoll, 71, died from massive acute haemolysis and multi-system failure after receiving incompatible blood transfusions during aortic aneurysm repair. Pre-operative blood samples from Stoll and another patient (Koven…

cardiothoracic surgeryanaesthesiadiagnosticprocedural

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