12 results
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…
61y · Female·Diffuse alveolar damage in a woman with restrictive lung disease following catar…
A 61-year-old woman with severe restrictive lung disease, obesity, cardiac failure, and diabetes underwent cataract surgery at a private day surgery centre on 13 August 2018. She was unable to lie flat and became hypoxic…
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…
0y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…
A 10-month-old boy died following elective cleft palate repair surgery complicated by post-operative respiratory distress and subsequent cardiorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pu…
44y · Female·Complications of a lung abscess with contributing factors of Down's syndrome and…
Melissa Cunningham, a 44-year-old woman with Down's syndrome and severe obesity, died from complications of a lung abscess. She required a CPAP machine for sleep apnoea, prescribed and monitored by Western Health since 2…
24y · Female·Cardiac conducting system disease leading to asystole against a background of a …
A 24-year-old woman with complex congenital cardiac disease, cerebral palsy, and hydrocephalus was admitted to a secondary hospital with a respiratory tract infection and bradycardia with left bundle branch block. She de…
75y · Male·Right haemothorax complicating intercostal catheter insertion for the treatment …
Giuseppe Costa, 75, died from right haemothorax following intercostal catheter insertion for pleural effusion drainage. Critical failures in clinical management included: inadequate documentation of pleural fluid drainag…
36y · Female·Complications of pneumonia and pulmonary emphysema with bullae formation; respir…
A 36-year-old woman with congenital chest wall abnormality, scoliosis, and difficult intubation history presented to a rural hospital with community-acquired pneumonia and sepsis. She had multiple 'red flag' indicators o…
80y · Female·Gas embolism complicating surgical repair of an atherosclerotic aortic aneurysm …
An 80-year-old woman with multiple comorbidities (COPD, renal impairment, cardiac disease) underwent complex endoluminal repair of a thoracoabdominal aortic aneurysm at a private hospital. The procedure required use of C…
75y · Female·Septicaemia as a result of lobar pneumonia; congestive heart failure also presen…
A 75-year-old woman died from septicaemia following a percutaneous tracheostomy procedure performed by a locum consultant on a Sunday. The procedure deviated significantly from the established ICU protocol: it was perfor…
20y · Female·Cerebral anoxia consequent upon a severe acute asthmatic event
Sally Anne Gordon, a 20-year-old with a 14-year history of severe brittle asthma, presented to Mount Gambier Hospital on 26 November 2000 with acute severe asthma unresponsive to initial treatment. After appropriate emer…
68y · Male·Internal haemorrhage due to coagulopathy and upper gastrointestinal varices, cir…
Robert Donald Rawson, a 68-year-old man with end-stage cirrhosis and multiple comorbidities, died hours after undergoing intercostal catheter insertion for pleural effusion drainage at Rockhampton Hospital. While the pro…
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