85 results
6y · Male·pneumonia complicating influenza A (H1N1) infection with secondary streptococcal…
Sebastian Parman, a 6-year-old boy, died from pneumonia complicating influenza H1N1 with secondary group A streptococcal infection causing scarlet fever, empyema and sepsis. Multiple clinical failures contributed: an inf…
4y · Female·Haemorrhage due to aorto-oesophageal fistula caused by ingestion of a button bat…
A 4-year-old girl died from aorto-oesophageal fistula and haemorrhage caused by a lithium button battery lodged in her oesophagus for at least 3 days. Critical diagnostic failures occurred: the initial GP failed to consi…
31y · Female·Pneumonia; combined drug toxicity (including marijuana), smoking, pathological o…
Georgia Cheal, a 31-year-old with complex medical history including chronic pain, major depression, and obesity, died from pneumonia exacerbated by combined drug toxicity from multiple prescription medications, cannabis,…
76y · Female·Immersion (with underlying cause undetermined in circumstances of a fall into a …
76-year-old woman with vascular dementia and wandering behaviour was found submerged in a courtyard water fountain at an aged care facility after a fall. She remained unattended in a hazardous area for approximately 51 m…
87y · Female·heart failure and probable pneumonia in an elderly lady complicated by morphine …
An 87-year-old woman with dementia, heart disease, and hypertension presented with chest pain and hypoxia. A locum doctor (Dr B.) administered 20mg morphine intramuscularly without reviewing the patient's notes, medical …
87y · Male·Complications of subdural haematoma and fractured hip following a traumatic inci…
Mr Mehmet Hasan, 87, died from complications of subdural haematoma and fractured hip following an alleged traumatic incident involving staff at Lorikeet Lodge Aged Care on 12 June 2010. Following transfer to hospital, hi…
79y · Female·pneumonia in the setting of acute peritonitis due to perforated stomach (operate…
Mrs Thelma Katherine Holt, a 79-year-old woman with multiple comorbidities including obesity, vascular disease, hypertension, and prior Nissen fundoplication, underwent placement of a second intragastric balloon on 11 Se…
Unknown·Three deaths with different primary causes: James Unicomb - acute toxicity due t…
Combined inquest into three deaths at Psyche South Clinic involving treatment failures: James Unicomb (22, 2005) from multi-drug overdose after naltrexone implant; Michael Poole (48, 2008) from ruptured aneurysm post-Rap…
Unknown·Toxicity from intravenous caesium, DMSO, and other substances administered as pa…
In May 2005, the Kathi Preston Memorial Health Centre (KPMHC) operated an unproven cancer therapy clinic from Dr B.'s home in Perth, Western Australia, administering intravenous treatment containing caesium, DMSO, and La…
29y · Female·Hypoxic Encephalopathy consequent upon Cardiorespiratory Arrest arising from eit…
Helen Grainger, 29, with polycystic kidney disease and asthma, underwent pregnancy termination at Lambton Road Day Surgery in April 2007. She developed anaphylaxis post-procedure (likely cephalosporin-triggered) with car…
32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …
A 32-year-old woman with schizophrenia, well-controlled on clozapine, became pregnant. Poor communication between her general practitioners, community mental health service, and the hospital meant the hospital was unawar…
28y · Female·bronchopneumonia complicating oxycodone toxicity
Melissa Jay Tatchell, aged 28 with severe anorexia nervosa (BMI 11.8, weight 29kg), died from bronchopneumonia complicating oxycodone toxicity. A locum doctor with no prior experience with oxycodone prescribed inappropri…
59y · Female·Subdural haemorrhage from blunt force trauma to head sustained in a backwards fa…
Lena Divola, a 59-year-old woman with intellectual disability, schizophrenia, and depression living in supported accommodation, sustained a head injury on 24 December 2007 when she fell backwards from a walker being push…
31y · Male·Overdose of quetiapine (Seroquel) in combination with alcohol
Travis Graham, a 31-year-old man with a history of mental illness, self-harm, and substance abuse, died from an overdose of quetiapine (Seroquel) combined with alcohol. He had previously overdosed on the same medication …
77y · Male·hypoxic-ischaemic encephalopathy and cerebral infarction due to upper airway obs…
A 77-year-old man with advanced dementia died from hypoxic-ischaemic encephalopathy caused by upper airway obstruction from a handkerchief. An agency carer placed a handkerchief in his breast pocket during morning care, …
1y · Female·pneumonia (staphylococcal pneumonia with bilateral bacterial pneumonia)
Jezelle Lisa Gordon, a 1-year-old child, died of staphylococcal pneumonia on 26 February 2006 in Port Hedland, Western Australia. She presented to Halls Creek Hospital on 25 February with fever, elevated respiratory rate…
87y · Male·multi organ failure due to septic shock complicating urinary tract infection and…
An 87-year-old man with atrial fibrillation on warfarin developed septic shock and multi-organ failure following traumatic bladder catheterisation. Two catheterisation attempts occurred on 15 July 2005: an unsuccessful a…
26y · Male·severe closed head injury associated with severe fractures of the cranial vault …
Two remand prisoners died by jumping from mezzanine floors at Adelaide Remand Centre. Andrew Gill (26) died 2 June 2005 after jumping 1 June; Simon Schaer (70) died 15 December 2005. Critical failure: police possessed in…
23y · Female·drowning and citalopram overdose
23-year-old woman with major depressive disorder presented to multiple healthcare providers on 17 March 2004 with suicidal ideation. She was referred to Flinders Medical Centre Emergency Department by her GP, where she w…
51y · Male·ischaemic heart disease
A 51-year-old prisoner died from ischaemic heart disease after suffering a cardiac event while being transferred between prison units. He had complained of chest pain to correctional officers, was directed to walk to the…
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