85 results
87y · Female·Natural causes in the context of multiple co-morbidities including a sacral ulce…
87-year-old woman died in aged care with a stage 4 sacral ulcer and multiple comorbidities. Key clinical lessons: (1) Systematic communication failures—family was not informed that a healed sacral wound re-emerged in Mar…
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…
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 · Male·multi-organ failure due to sepsis on a background of sacral pressure ulcer
An 86-year-old man died from multi-organ failure due to sepsis from a stage 4 sacral pressure ulcer after 61 days in a regional hospital. Critical failures included delayed pressure injury risk assessment (7 days overdue…
33y · Male·complications of acute peritonitis caused by rupture of a duodenal ulcer
Sony William Tran-Bui, aged 33, died from acute peritonitis caused by a ruptured duodenal ulcer while in custody at Silverwater Correctional Centre in November 2013. The death was not preventable given the sudden, unexpe…
54y · Male·Extensive burns due to detonation of LPG gas cylinder
A 54-year-old man with chronic severe depression, grief from his wife's sudden death, severe debilitating skin condition, and alcohol dependence called emergency services on 12 December 2015, warning them not to approach…
53y · Male·Choking on food bolus in pharynx, with Huntington's disease and coronary atheros…
Paul Joseph Milward, aged 53 with Huntington's disease causing cognitive impairment and swallowing difficulties, died from choking on a bread sandwich while unsupervised in his aged care room. His care plan specified min…
35y · Male·Fentanyl toxicity
David Veech, aged 35, died of accidental Fentanyl toxicity while residing at Tarlo Intensive Residential Support Service. He extracted Fentanyl from prescribed transdermal patches and injected it intravenously. Despite b…
37y · Male·cardiac arrhythmia
A 37-year-old man died in custody from cardiac arrhythmia, with morbid obesity and concurrent psychotropic medications carrying QT-prolongation risk identified as contributing factors. Key clinical lessons include: (1) p…
32y · Male·Multidrug overdose
A 32-year-old man with a history of polysubstance abuse, schizoaffective disorder, and chronic pain died from multidrug overdose at home. He had obtained fentanyl, clonazepam, diazepam, methadone, and other drugs from mu…
22y · Female·compression of the neck consistent with hanging
22-year-old Deborah McKenzie, an Aboriginal woman, died by hanging on 13 March 2013 after a complex sequence of failures in mental health care and police procedures. She had reported her partner Shane Woods to police for…
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…
50y · Female·Hanging
Jacinta Dwyer, a newly appointed magistrate with limited criminal law experience, developed severe anxiety and depression within months of taking office in February 2017. Despite supportive interventions from senior judg…
48y · Female·Sepsis due to pulmonary and cutaneous infections, with urinary tract infection a…
A 48-year-old tetraplegic woman died from sepsis originating from a necrotic sacral pressure wound. Multiple system failures contributed: inadequate pressure sore prevention at the disability care provider (air mattress …
75y · Female·organ failure due to sepsis, likely from infected pressure sores, in the context…
Maria Carmel Niceforo, a 75-year-old woman with poorly controlled diabetes and ischaemic heart disease, died from septic shock secondary to extensive infected sacral pressure wounds. She received home care through KinCar…
63y · Male·blunt head and chest trauma from motor vehicle collision
Edmund Smordowski, a 63-year-old cyclist, was struck from behind by an 83-year-old driver, Kevin Rice, and died from blunt head and chest trauma. The collision occurred because Rice was unable to maintain his vehicle wit…
84y · Female·Positional asphyxia due to head and neck entrapment between mattress and bed pol…
Barbara Westcott, aged 84, died of positional asphyxia on 31 March 2012 when her head and neck became trapped between her mattress and a bed pole at Vaucluse Gardens aged care facility in Hobart, Tasmania. The bed pole, …
44y · Female·Combined drug toxicity (oxycodone, diazepam, and pregabalin)
Melissa May, a 44-year-old woman with chronic pain and opioid dependence, died from combined drug toxicity on 16 December 2013. She had been prescribed oxycodone, diazepam, and pregabalin by doctors at Rich River Health …
45y · Female·Combined effects of widely metastatic (end-stage) carcinoma of the cervix and br…
Teressa Maree Beswick, a 45-year-old woman with end-stage metastatic cervical cancer, died from the combined effects of her cancer and bronchopneumonia accelerated by a critical medication error. On 23 October 2014, she …
75y · Female·hypovolaemic shock following uncontrolled blood loss from mini-liposuction stem …
A 75-year-old woman with advanced frontal lobe dementia died from hypovolaemic shock following uncontrolled bleeding after an unproven stem-cell liposuction procedure. Critical failures included: failure to cease anticoa…
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