152 results
Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…
Two obese patients died from hypoxic-ischaemic encephalopathy following cardio-respiratory deterioration post-operatively at a private hospital without overnight medical cover. John Ryan (54) deteriorated within hours of…
5y · Female·Multiple injuries sustained in a collision between a semi-trailer and a V/Line p…
A semi-trailer collided with a V/Line passenger train at a level crossing near Kerang on 5 June 2007, killing 11 passengers instantly or within hours. The collision was caused by a heavy vehicle driver unfamiliar with th…
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…
64y · Male·aspiration pneumonia following insertion of a jejunostomy tube
Ronald Brockel, a 64-year-old with cerebral palsy, oropharyngeal dysphagia, and recurrent aspiration pneumonia, underwent insertion of a feeding jejunostomy tube (FJT) on 23 December 2004 to bypass his stomach and improv…
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…
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…
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…
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…
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…
70y · Female·Hypoxic/Ischaemic Encephalopathy consequent upon Cardiorespiratory Arrest and Co…
Beverly Ann Murphy, 70, underwent hysterectomy for endometrial carcinoma on 2 April 2008 at Royal Hospital for Women. The complex surgery was complicated by iatrogenic small bowel perforations. Post-operatively, wound de…
27y · Male·cardiac arrhythmia during restraint; mechanism involved hypoxia and asphyxiation…
Warwick Andrew Ashdown, a 27-year-old male with severe treatment-resistant paranoid schizophrenia, died at Graylands Hospital on 12 October 2007 from cardiac arrhythmia during physical restraint. After assaulting another…
62y · Male·Brain swelling associated with cerebral infarction; drainage acute on chronic su…
John Hemingway, a 62-year-old man with cerebral palsy, hydrocephalus, and epilepsy, sustained a head injury when a vehicle rolled backward and struck him while he was in a wheelchair. The driver, an international student…
42y · Male·Combined effects of moderately severe physical exertion; a lateral vascular neck…
Carl Grillo, a 42-year-old man, died after police detained him during a foot chase in Spring Hill, Brisbane. Following an initial wrestling struggle, a lateral vascular neck restraint was applied by Senior Constable Jake…
29y · Male·Hypoxia as a result of cardiac arrest (ventricular fibrillation) from unknown ca…
David Thomas, 29, collapsed from ventricular fibrillation while exercising at a Melbourne fitness centre on 3 October 2007 and died from hypoxic brain injury. The critical failure was inadequate pre-hospital response: on…
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 O., with similar mechanisms: bowel perforation leading to peritonitis and sepsis. Mrs Leonard (77) underwent laparoscopic surger…
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…
20y · Male·Widespread hypoxic brain injury secondary to cardiac arrhythmia, ventricular fib…
Shayne McMahon, 20, died on 7 April 2007 from cardiac arrhythmia and hypoxic brain injury after exposure to butane from a severed LPG gas line at North Star Holiday Resort. As an unlicensed apprentice plumber/gasfitter, …
Female·Combination of liver failure, blood loss and shock following needle biopsy
Alyssa, a 9-week-old infant, died from hemorrhage following a liver biopsy at Monash Medical Centre. She had persistent jaundice, and biopsy was undertaken to investigate potential biliary atresia. Post-operatively, nurs…
Male·Myocardial failure resulting from excessive pulmonary blood flow and consequenti…
One-month-old Liam Woodcock, born extremely prematurely at 27.5 weeks gestation weighing approximately 1 kilogram, died from myocardial failure secondary to excessive pulmonary blood flow in the context of severe congeni…
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