89 results
72y · Female·Intrathecal toxicity of bupivacaine and morphine
A 72-year-old woman with terminal metastatic parotid cancer died from intrathecal toxicity of bupivacaine and morphine. She was admitted to Ashford Hospital for pain management of pathological pelvic fractures. An intrat…
66y · Female·Multi-organ failure associated with haemorrhage and sepsis following cholecystec…
Mrs Jeanette Brown, 66, died from multi-organ failure following post-operative haemorrhage after elective laparoscopic cholecystectomy. Arterial clips applied to the cystic artery during surgery were inadequately secured…
43y · Male·Hypoxic brain injury secondary to haemopericardium and tamponade complicating ru…
Mr Trevor McDonald, 43-year-old male, died from hypoxic brain injury following cardiac tamponade complicating coronary angioplasty. During elective PCI at Frankston Hospital, he sustained right coronary artery perforatio…
42y · Male·Hypoxic encephalopathy in the setting of recent acute myocardial infarction with…
Ruben Chand, a 42-year-old male, suffered a fatal hypoxic brain injury during emergency re-intubation in ICU. After an initially reasonable extubation decision, he deteriorated and required urgent re-intubation. The proc…
37y · Male·Respiratory arrest in association with medication drug effect and alcohol intoxi…
David James Lee, a 37-year-old Aboriginal man with schizophrenia, died on 15 July 2007 at Port Hedland Regional Hospital from respiratory arrest associated with medication effect and alcohol intoxication. He arrived at t…
75y · Female·hypovolaemic shock from excessive blood loss
Lorraine McDonald, age 75, died from hypovolaemic shock due to massive intraoperative bleeding during an anterior resection for rectosigmoid adenocarcinoma. Critical deficiencies included: no pre-admission clinic assessm…
34y · Male·Air embolism and severe haemorrhage due to perforation of the right subclavian v…
Darryl Smith, aged 34, died following emergency surgery for a fractured clavicle at Sunnybank Private Hospital. During the final drilling of the sixth screw hole, the surgeon's drill penetrated the underlying right subcl…
Female·Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perfor…
Two elderly women died following vaginal prolapse surgery performed by the same surgeon, Dr Onuma, with similar mechanisms: bowel perforation leading to peritonitis and sepsis. Mrs Leonard (77) underwent laparoscopic sur…
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…
1y · Female·acute on chronic respiratory failure
Kara Compton, aged 22 months with Down's syndrome and chronic respiratory disease requiring home oxygen, died from acute on chronic respiratory failure following a dog bite attack. Injuries caused blood loss which, combi…
83y · Female·Haemorrhage due to mitral valve disease (surgically repaired); specifically haem…
An 83-year-old woman died from haemorrhage following mitral and tricuspid valve repair surgery. During intra-operative testing of the repaired mitral valve using Blake's tubing (soft rubber tubing with a bevelled end) at…
67y · Male·Complicated endotracheal tube insertion due to or as a consequence of recent clo…
Oliver Steven McVey, a premature twin born at 31 weeks gestation weighing 1036g, died from complications of endotracheal tube re-insertion at 67 days of age. Following successful surgical ligation of a patent ductus arte…
62y · Female·Haemorrhage caused by abdominoperineal excision of the rectum
A 62-year-old woman died of uncontrollable haemorrhage following an abdominoperineal excision of the rectum (APER) at a remote hospital. The coroner found the operation itself was inappropriate: performed for undiagnosed…
28y · Male·hypovolemia secondary to haemorrhage from operative exploration of multiple stab…
A 28-year-old Aboriginal male died from hypovolemic shock following operative exploration of multiple stab wounds to the thigh. The death was preventable. Critical failures included: delayed surgery from Friday to Saturd…
49y · Female·Intra-abdominal haemorrhage, septic and haemorrhagic shock as a result of a lapa…
Deborah Burgen died from intra-abdominal haemorrhage complicated by septic shock following delayed emergency surgery for bowel obstruction. She attended the emergency department six times over eleven days with identical …
31y · Male·Upper airway obstruction due to pharyngeal abscess caused by dental abscess, whi…
Karl Scholz, 31-year-old male, died from upper airway obstruction due to pharyngeal abscess originating from untreated dental infection. He presented with severe facial cellulitis and abscess following dental procedures …
30y · Female·Multi-organ failure due to multiple transfusions required for post-operative ble…
Ms Cvitic, a 30-year-old woman with cervical cancer, underwent radical hysterectomy on 11 February 2002. She collapsed on 14 February with signs of hypovolaemic shock (haemoglobin 5.3 g/dL). Dr W. performed emergency lap…
21y · Male·multi-organ failure due to septicaemia of mixed respiratory (bronchopneumonia) a…
Shannon Tang, a 21-year-old from Singapore with severe obesity (BMI 52) and multiple comorbidities including sleep apnoea, underwent elective laparoscopic gastric bypass surgery performed by Dr F.. He died on day 7 post-…
31y · Female·cerebral anoxia following attempted intubation pre-surgery in a woman with torti…
Rachael Anne Rasmussen, a 31-year-old mother of three with severe neck deformities (torticollis, dysmorphia, short rigid neck), died on 17 June 2003 from cerebral anoxia following attempted intubation at Joondalup Health…
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…
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