138 results
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…
56y · Male·Hypoxia and cardiac arrest with contributing conditions of Ischaemic Heart Disea…
A 56-year-old man with diabetes, ischaemic heart disease, morbid obesity, and an implanted defibrillator underwent minor toe debridement surgery. The anaesthetist failed to conduct an adequate pre-operative assessment, u…
53y · Male·Complications of burns sustained in a blast
A 53-year-old qualified boiler maker died from complications of severe burns sustained in a gas explosion. While attempting to remove a refrigeration compressor from a hotel cellar with an unqualified colleague, they cut…
39y · Male·Hypoxic/Ischaemic Encephalopathy due to Cerebral Arterial Gas Embolism
Phillip Ibrahim, a 39-year-old man recovering well from community-acquired pneumonia in ICU, suffered a fatal cerebral air embolism on 28 October 2014. A CVAD removal order was given at midday but the device remained in …
24y · Male·Hypoxic-ischaemic encephalopathy, due to or as a consequence of cardiac arrest, …
Hamid Khazaei, an Iranian asylum seeker aged 24, died on 5 September 2014 after contracting a leg infection (Chromobacterium violaceum) on Manus Island while in immigration detention. His death was preventable and result…
3y · Male·Influenza A infection (Type H3N2)
Aidan Mara, a 3-year-old boy with influenza A pneumonia and hyponatraemia, collapsed and died from cardiovascular failure on hospital day 3. Critical clinical lessons include: (1) distinguishing SIADH from dehydration ea…
82y · Male·Cardiomegaly, myocardial fibrosis and ischaemic coronary artery disease in the c…
An 82-year-old man with extensive comorbidities underwent colonoscopy with argon plasma coagulation (APC) for bleeding angiodysplasia. Prolonged activation intervals during the final third of the procedure caused full-th…
70y · Male·blunt force head injury (operated)
A 70-year-old Torres Strait Islander man died from blunt force head injury sustained when police forcibly woke and directed him to leave a private residence where he was sleeping. Police lacked legal powers to intervene:…
78y · Female·multi-organ failure due to haemorrhage into the abdomen, pelvis and retroperiton…
78-year-old Jehovah's Witness died from multi-organ failure secondary to intra-abdominal and retroperitoneal haemorrhage following extensive anterior and posterior lumbar spinal fusion surgery. The patient had multiple c…
59y · Female·Global cerebral oedema due to hypoxic cerebral ischaemia following cardiac arres…
59-year-old woman admitted with newly diagnosed grade 4 glioblastoma underwent surgery 16 days later after delays during consultant's planned leave. Post-operative complications included ischaemic stroke confirmed on ima…
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…
75y · Female·septic complications following surgical resection of duodenal ampullary adenoma
A 75-year-old woman died of sepsis from bile leaking into her abdomen after elective surgery to remove a pre-malignant tumour adjacent to the bile duct. The coroner found multiple preventable failures: inadequate pre-ope…
66y · Female·retroperitoneal haemorrhage due to anticoagulation following right cerebrovascul…
A 66-year-old woman died from retroperitoneal haemorrhage following anticoagulation for stroke caused by intra-arterial central venous catheter placement. The catheter was mistakenly inserted into the right carotid arter…
67y · Male·ischaemic heart disease
A 67-year-old man with ischaemic heart disease and paroxysmal atrial fibrillation underwent arthrotomy for septic arthritis of the knee. He developed post-operative delirium attributed to anaesthesia, analgesics (tramado…
0y · Male·Complications of hypoxic ischaemic encephalopathy secondary to recurrent episode…
Kyran Day, a 6-month-old boy, presented to Shoalhaven District Memorial Hospital with vomiting and lethargy on 19 October 2013. He was initially assessed and diagnosed with gastroenteritis based on recent rotavirus vacci…
77y · Male·Stroke; cardiogenic shock; severe aortic stenosis with three vessel coronary art…
Mr Neitsch, a 77-year-old with severe aortic stenosis, peripheral vascular disease, and reduced left ventricular function, underwent elective coronary angiography at Princess Alexandra Hospital on 21 May 2015. The proced…
66y · Male·Multi-system failure and ischaemic gut after left nephrectomy complicated by mas…
A 66-year-old man died from multi-system failure and ischaemic bowel following laparoscopic left nephrectomy complicated by massive haemorrhage and vascular injury. During surgery for renal carcinoma, the surgeon attempt…
42y · Female·Global cerebral ischaemia in a setting of anaesthesia
A 42-year-old woman died from global cerebral ischaemia following cardiac arrest during anaesthesia for a late-term termination of pregnancy. The anaesthetist, Dr McAllister, failed to obtain or ensure a functioning puls…
62y · Male·Global cerebral ischaemia secondary to intra-operative hypotension following the…
A 62-year-old man died from global cerebral ischaemia following intra-operative hypotension after protamine administration during a cardiac ablation procedure. He had suffered a severe hypotensive reaction to protamine 8…
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