36 results
67y · Male·Multi-organ failure secondary to acute myocardial infarction secondary to in-ste…
Christopher Doughty, 67, was admitted to Hervey Bay Hospital on 17 September 2021 with a life-threatening gastrointestinal bleed two months after receiving coronary stents. The bleed was likely caused by dual antiplatele…
36y · Male·Drowning
Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical ps…
86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall
James Reilly, 86, fell at home on 8 September 2024 sustaining rib fractures that caused a fatal left haemothorax. Paramedics attended but he declined transfer. When facial droop developed, he was admitted with presumed t…
41y · Male·acute, severe hydrocephalus contributed to by longstanding chronic hydrocephalus…
Benjamin Cullen, aged 41, died on 25 February 2021 from acute severe hydrocephalus secondary to a brain tumour abutting the cerebral aqueduct. He suffered three seizures on 23 February 2021, two days after release from P…
42y · Female·Pneumonia, underlying severe cerebral palsy
Rachel Piskun, aged 42, died from pneumonia complicated by severe cerebral palsy. She had severe disabilities requiring 24-hour care in supported accommodation. During a September 2021 hospitalization, compression stocki…
32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity
A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with …
62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…
A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…
74y · Female·Post-operative exacerbation of delirium and terminal functional deterioration du…
Jane Ann Chapman, 74, presented to hospital with delirium, fever and suspected urinary tract infection. She fell from an Emergency Department trolley bed, sustaining a neck of femur fracture requiring surgery. Post-opera…
95y · Male·Head injuries (subarachnoid haemorrhage, frontal bone fracture and contrecoup) s…
A 95-year-old man admitted to hospital for fluid overload and cellulitis related to heart failure fell in his hospital room on day 11 of admission whilst attempting to walk to the bathroom without his walker or assistanc…
64y · Male·hypoxic-ischaemic encephalopathy and its complications following cardiac arrest …
Christopher Lens, a 64-year-old man with schizophrenia under guardianship at a nursing home, died from hypoxic-ischaemic encephalopathy following cardiac arrest due to upper airway obstruction after choking on a peanut b…
66y · Male·Cardiac arrhythmia in a man with arteriosclerotic cardiovascular disease, pulmon…
Bradley Stinson, a 66-year-old prisoner with a long history of heavy smoking and alcohol use, died from cardiac arrhythmia in the setting of arteriosclerotic cardiovascular disease, pulmonary thromboembolism, and metasta…
75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis
A 75-year-old woman with chronic pain and previous staphylococcal infections presented to Glen Innes District Hospital with a swollen, warm right knee 10 days after a corticosteroid injection. Junior doctor Dr M. appropr…
54y · Female·unascertained
Carole Livesey, a 54-year-old woman with severe anorexia nervosa and major depression, absconded from Rockingham Hospital psychiatric unit on 3 October 2017 during an escorted walk in hospital grounds. She had been an in…
68y · Male·Metastatic Pancreatic Adenocarcinoma
Ivan Leo Goolagong, a 68-year-old Wiradjuri man, died of metastatic pancreatic adenocarcinoma while in Long Bay Prison Hospital Medical Subacute Unit in July 2017, five months after undergoing a Whipple procedure. The co…
45y · Male·Global cerebral hypoxia following cardio-respiratory collapse due to anaphylaxis…
A 45-year-old man with poorly controlled diabetes, ischaemic heart disease, and recurrent lower limb infections died from anaphylaxis to intravenously administered flucloxacillin. He presented with sepsis secondary to a …
75y · Male·Right haemothorax complicating intercostal catheter insertion for the treatment …
Giuseppe Costa, 75, died from right haemothorax following intercostal catheter insertion for pleural effusion drainage. Critical failures in clinical management included: inadequate documentation of pleural fluid drainag…
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…
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 …
44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)
Jimmy James, a 44-year-old man, died from pneumonia with multiple left-sided rib fractures secondary to a physical assault. He presented to Westmead Hospital ED with clinical signs of septic shock (tachypnoea, hypoxia, h…
91y · Male·Hypostatic pneumonia due to traumatic fracture of C7 and subluxation of C6/7, re…
Maxwell Delaney, 91, was a resident at Eliza Purton Care Home in Tasmania with complex medical history including Alzheimer's disease, osteoporosis, and prior falls. On 24 January 2015, he fell while seated on a lightweig…
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