259 results
15y · Male·Cerebral ischaemia in a young man with a blocked ventricular peritoneal shunt an…
Vaughn Richard Rasmussen, a 15-year-old boy with congenital abnormalities and a ventricular-peritoneal (VP) shunt, died from cerebral ischaemia caused by acute blockage of his VP shunt on 17 November 2009. Between 12-16 …
17y · Female·Acute Lymphocytic Meningitis and Focal Myocarditis
Amy Lee Dawkins, 17, presented twice to Rockingham General Hospital ED within two weeks with severe headaches, myalgias, and vomiting. On 28 December 2008, she was discharged with a diagnosis of viral upper respiratory t…
63y · Female·bile peritonitis as a complication from a laparoscopic cholecystectomy
A 63-year-old woman died from bile peritonitis following laparoscopic cholecystectomy. The surgeon's intraoperative management was appropriate with no identified injuries. However, critical clinical deterioration on post…
31y · Male·Acute colonic pseudo-obstruction; death certificate amended to 'unascertained' -…
Cameron Yeates, a 31-year-old man with intellectual disability (IQ 64) and longstanding gastrointestinal issues, died from acute colonic pseudo-obstruction with underlying malnourishment. Key clinical lessons: (1) severe…
62y · Male·multi organ failure due to atypical pneumonia
William Gripton, 62 years old with post-polio syndrome, presented to Kangaroo Island Hospital with upper respiratory tract infection that progressed to atypical pneumonia causing multi-organ failure and death. Critical c…
24y · Male·neck compression due to hanging
A 24-year-old man with depression and anxiety died by hanging in March 2009, three weeks after hospital discharge following an overdose. Critical clinical lessons emerge: (1) discharge summaries from psychiatric admissio…
37y · Male·combined ethanol and drug toxicity
Kenneth Agnew, a 37-year-old man resident in aged care, died from combined ethanol and drug toxicity involving methadone and benzodiazepines. He had hepatitis C and fatty liver disease. Critical clinical lessons include:…
51y · Female·Complications of anorexia nervosa
A 51-year-old woman with severe anorexia nervosa, BMI 12.1, was admitted to hospital acutely unwell with hypothermia, bradycardia, heart block, and extreme malnutrition. She was discharged after only 2 days with minimal …
0y · Female·perinatal pneumonia in association with meconium aspiration
Baby Sharinka Patricia Little, born prematurely at 35 weeks at Dalwallinu Hospital on 20 March 2008, died from perinatal pneumonia with meconium aspiration the same day. Critical clinical failures occurred during her nin…
85y · Female·Pulmonary embolus secondary to deep vein thrombosis, precipitated by minor fall
An 85-year-old woman died from pulmonary embolism secondary to deep vein thrombosis following a minor fall. She was admitted to Maryborough Hospital with chest infection and abdominal pain. Despite being identified as hi…
Male·Suicide: hanging (Al-Akabi, Saunders); diving from balcony (Rauluni)
Three immigration detainees died by suicide at Villawood Detention Centre in Sydney within three months in 2010. Josefa Rauluni (Fijian) jumped from a balcony on 20 September after being informed of imminent removal desp…
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…
29y · Male·acute bronchopneumonia complicated by multi-drug toxicity
Nicholas Ang, aged 29, with schizoaffective disorder, died from acute bronchopneumonia complicated by multi-drug toxicity while in a psychiatric unit. Admitted 12 August 2005, he was on clozapine, valproic acid, and clon…
Unknown·Lignocaine toxicity following dental surgery with atherosclerotic and valvular h…
George Godden died at Prince of Wales Hospital on 22 February 2007 from lignocaine toxicity following dental surgery. His post-extraction gingival bleeding was treated with gauze soaked in co-phenylcaine spray, a medicat…
93y · Female·Complications of fractured neck of femur in a woman with congenital heart failur…
Annie Kane, 93, with congestive heart failure and hypertension, sustained a fractured neck of femur following an unwitnessed fall at Jasmine Lodge supported residential service in July 2009. The fall occurred in an area …
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…
81y · Male·Retropubic and retroperitoneal haemorrhage complicating pelvic fractures with co…
An 81-year-old man died from retropubic and retroperitoneal haemorrhage complicating pelvic fractures sustained in a fall at church. He was on warfarin for atrial fibrillation with an excessive INR of 4.6 at the time of …
50y · Female·acute heart failure in association with acute on chronic obstructive airways dis…
Donna Lillian Barnes, a 50-year-old woman with chronic schizophrenia and multiple physical comorbidities including morbid obesity, asthma, and poor mobility, died of acute heart failure associated with acute-on-chronic o…
68y · Male·Complications following colon surgery on a background of cirrhosis of the liver;…
Ian Donald Patience, 68, died on 10 June 2007 from complications following colon surgery in the setting of cirrhosis. He underwent right hemicolectomy at Sydney South West Private Hospital on 31 May 2007 for colorectal c…
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