796 results
77y · Female·Pulmonary thromboembolism secondary to deep vein thrombosis of the left leg
A 77-year-old woman with Factor V Leiden thrombophilia and history of PE presented to a rural urgent care centre on 19 April 2017 with shortness of breath and chest pain. She was examined by Dr H. who considered but dism…
89y · Male·fractured cervical spine (C5 inferior articular process fracture) due to unwitne…
An 89-year-old man with Parkinson's disease fell at home on 16 August 2016, sustaining a cervical spine fracture. Initial CT imaging missed the C5 inferior articular process fracture, reporting only a paraspinal haematom…
59y · Male·ischaemic heart disease in the context of acute-on-chronic kidney failure associ…
Arthur James Bonney, a 59-year-old prisoner with advanced cardiac disease, chronic kidney disease, and diabetes, underwent a CT scan with iodinated contrast on 30 July 2015 at Fiona Stanley Hospital. Critical failures oc…
27y · Male·Injuries sustained in descent from height
A 27-year-old man with schizophrenia was brought to Northern Hospital ED by police under Mental Health Act section 351 after threatening suicide and injecting testosterone. The Emergency Department doctor (Dr K.) assesse…
43y · Male·hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic …
Jay Alan Paterson, a 43-year-old man with chronic pain and opioid dependence, died from hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic upper airway injury. He obtained 296 oxycodone table…
86y · Female·subdural haemorrhage due to or as a consequence of a fall
Ms SME, an 86-year-old resident at a Blue Care nursing home, suffered a fatal subdural haemorrhage following a fall from bed during a sponge bath on 18 January 2016. She died on 21 January 2016. Clinical lessons include:…
42y · Female·Incised injury to the neck
A 42-year-old woman with depression and suicidal ideation died by self-inflicted neck laceration while admitted to a psychiatric inpatient unit. She had been assessed as low risk and placed on 30-minute observations. Cli…
Unknown·Bushfire caused by demolition of surplus explosive ordnance at Marrangaroo Train…
The State Mine Fire started on 16 October 2013 when ADF personnel conducted a demolition serial at Marrangaroo Training Area near Lithgow, NSW, to dispose of surplus explosive ordnance. The fire spread extensively across…
62y · Male·blunt trauma of chest and abdomen
Terrence Close, a 62-year-old traffic controller, died on 5 February 2013 after being struck by a vehicle while managing traffic at a crack-sealing worksite on Vermont Road, Launceston. The coroner found multiple systemi…
97y · Male·Complications of a fractured left neck of femur (operated), sustained in a fall
A 97-year-old man with vascular dementia, visual impairment, gait instability and multiple falls risk factors fell during a supervised outing from his aged care facility and sustained a fractured neck of femur. Despite b…
55y · Male·positional asphyxia, with sedation as an underlying risk factor
Kevin O'Halloran, a 55-year-old with chronic schizophrenia, presented with acute severe behavioural disturbance related to medication changes and possible substance use. He received substantial intravenous sedation (75mg…
67y · Female·unable to determine
A 67-year-old woman was found deceased in her home after an 8-day period since last being seen alive. The cause of death could not be determined at autopsy due to decomposition. Critical clinical lessons emerged from the…
3y · Female·Multiple crush injuries to the chest and abdomen
Indy Henderson, aged 3, died from crush injuries when a sandstone Anzac memorial headstone collapsed at a public venue while she was playing nearby. The headstone was inadequately fixed using silicone-coated dowels inste…
59y · Female·Mechanical (traumatic) asphyxia as result of motor vehicle incident
Julie Morrell, a 59-year-old school bus driver, was fatally crushed when an unmanned bus rolled forward in a carpark. After dropping passengers at Humpty Doo Hotel, she closed the bus doors using an external switch but f…
58y · Female·lymphangitic carcinomatosis leading to hypoxaemic respiratory failure and cardia…
June Nutter, a 58-year-old woman presenting with weight loss, anorexia, and unexplained shortness of breath, underwent gastroscopy and colonoscopy at a private hospital to investigate suspected gastric pathology. She had…
34y · Female·Complications of fall with fractured ankle and subsequent deep venous thrombosis…
Anna Bowditch, aged 34, died from complications of deep venous thrombosis (DVT) with pulmonary embolism and paradoxical stroke following elective fracture repair surgery. She had multiple known DVT risk factors: immobili…
43y · Female·cardiac arrhythmia (unascertained), probably fatal cardiac dysrhythmia
A 43-year-old woman collapsed at home and was found in cardiac arrest after 20-25 minutes. Ambulance arrived and recognised ventricular fibrillation but failed to defibrillate for approximately 20 minutes, despite protoc…
42y · Male·Drowning
A 42-year-old man with Prader-Willi syndrome and obsessive-compulsive tendencies drowned at Phillip Island while on a supported holiday organised by Wesley Mission. The coroner found that planning for the four-client hol…
57y · Male·sepsis and multiple organ failure secondary to aspiration pneumonia
Timothy Fenton, a 57-year-old intellectually disabled man on antiepileptic medications, developed a small bowel ileus after presenting with vomiting and diarrhoea. Following emergency laparotomy, his nasogastric tube was…
54y · Male·hypoxic-ischaemic encephalopathy resulting from neck compression due to entrapme…
Jorge Castillo-Riffo, a 54-year-old construction worker, died from hypoxic-ischaemic encephalopathy resulting from neck compression. While working on a scissor lift to patch post-tensioning pockets on a concrete slab edg…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.