52 results
44y · Female·Pulmonary thromboembolism complicating a fractured left ankle (not operated), su…
A 44-year-old woman died from pulmonary thromboembolism 27 days after sustaining a Weber B ankle fracture from a fall. She was managed conservatively with a CAM boot then below-knee cast, with progressive immobilisation …
26y · Female·Pulmonary thromboembolism due to deep vein thrombosis (left leg) due to fracture…
A 26-year-old woman with a tibia fracture died from pulmonary embolism due to deep vein thrombosis. Despite multiple risk factors (obesity, oral contraceptive use, vaping, leg immobilization, prolonged immobility), no fo…
71y · Male·Complications following a right hepatic artery injury following an open cholecys…
A 71-year-old man with myelofibrosis and prior abdominal surgery died from complications of a right hepatic artery injury during open cholecystectomy for acute cholecystitis. The operative decision was reasonable and the…
26y · Male·Multi-organ failure due to pneumococcal septic shock
A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…
69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…
Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…
27y · Male·acute myeloid leukaemia
Hayden Dawes, aged 27, died from acute myeloid leukaemia (AML) while in custody at Mannus Correctional Centre on 30 December 2018. He had previously been treated for Hodgkins Lymphoma with BEACOPP chemotherapy (2014-2016…
67y · Male·Intracranial haemorrhage complicating coronary artery bypass graft surgery follo…
A 67-year-old man died from intracranial haemorrhage following coronary artery bypass graft surgery. He had suffered a right coronary artery dissection during percutaneous coronary intervention at Sunshine Hospital and w…
66y · Male·infectious complications of plasmablastic myeloma
Mati Tamwoy, a 66-year-old Aboriginal man, died in ICU from infectious complications of plasmablastic myeloma after 661 days on remand. He received excellent oncological care including chemotherapy and radiotherapy. Howe…
61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed
A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…
75y · Male·End stage myelodysplastic syndrome and end stage renal failure on a background o…
A 75-year-old man died in prison custody from end-stage myelodysplastic syndrome and renal failure on a background of ischaemic heart disease, hypertension, valvular disease, and metastatic prostate cancer. He was admitt…
70y · Male·haemoperitoneum secondary to ruptured spleen following colonoscopy
Alan Edward Stewart, aged 70, died from haemoperitoneum due to splenic rupture following routine colonoscopy at Royal Melbourne Hospital on 15 August 2018. The splenic injury was caused by mechanical trauma from the colo…
0y · Male·multifactorial with severe hypoxia/hypotension which occurred in the background …
Everett Carleton died at birth following an emergency caesarean section complicated by unexpected placenta praevia and umbilical cord transection. The placenta was incorrectly reported as posterior on ultrasound, though …
76y · Male·pulmonary thromboembolism in the setting of deep vein thrombosis
A 76-year-old man with a history of unprovoked DVT/PE on lifelong warfarin was admitted with COVID-19 and developed a bleeding duodenal ulcer requiring endoscopic treatment. Warfarin was ceased to prevent further bleedin…
29y · Male·Pulmonary thromboembolism secondary to deep venous thrombosis
A 29-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis (DVT) following a suicide attempt by hanging. He was admitted to ICU and appropriately commenced on prophylactic enoxaparin 40mg dai…
87y · Male·Metastatic carcinoma of the prostate with complications (end-of-life palliative …
Errol Warren Bartlett-Torr, aged 87, died of metastatic prostate cancer on 20 June 2021 whilst in prison custody and receiving palliative care at Bethesda Hospital. Clinical lessons include: (1) elevated PSA findings sho…
64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …
Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart fai…
45y · Male·Intra-abdominal haemorrhage due to ruptured spleen due to splenomegaly due to ci…
Hayward Rasmussen, a 45-year-old man with cirrhosis and severe splenomegaly, died from intra-abdominal haemorrhage due to ruptured spleen while in custody. He collapsed in prison after sustaining possible rib injuries fr…
37y · Male·Pulmonary thromboembolus due to left leg deep vein thrombosis
A 37-year-old Aboriginal man died of pulmonary thromboembolism due to deep vein thrombosis while incarcerated. He presented to hospital on his birthday with lethargy, shortness of breath, and tachycardia. Initial assessm…
45y · Male·Haemorrhagic transformation of cerebral infarction, due to bilateral internal ca…
David Smith, aged 45, died from haemorrhagic transformation of cerebral infarction secondary to essential thrombocytosis with bilateral internal carotid artery thrombosis. He developed an acute ischaemic stroke on 9 July…
71y · Male·End-stage chronic obstructive pulmonary disease and atherosclerotic heart diseas…
Colin Albert Winter, a 71-year-old prisoner who died from end-stage COPD and atherosclerotic heart disease, received comprehensive medical care during 33 years of incarceration at Casuarina Prison. Key clinical lessons i…
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