102 results
85y · Male·Incised wounds to the wrist
An 85-year-old man with myelodysplasia and severe hip pain from an ischiorectal abscess died from incised wrist wounds sustained in a nursing home while in palliative care. He had expressed wishes to die, discussed eutha…
75y · Female·Complications including acute pancreatitis and refractory intra-abdominal sepsis…
Lee Milcherdy, 75, died from complications including acute pancreatitis and refractory intra-abdominal sepsis following an unnecessary ERCP procedure. An MRCP scan on 12 October 2018 showed no gallstone, making the plann…
57y · Male·Sepsis from ischemic bowel due to superior mesenteric artery thrombus
Trevor Peterson, a 57-year-old with chronic gut ischemia, underwent mesenteric artery stenting in February 2020. Discharge instructions emphasising dual antiplatelet therapy (DAPT) were not clearly communicated to the va…
54y · Male·Bowel ischaemia resulting from acute thrombosis of superior mesenteric artery an…
Anthony Barrett died from bowel ischaemia caused by acute thrombosis of his superior mesenteric artery and coeliac artery stents post-operatively. He had undergone left total knee replacement surgery at Fairfield Hospita…
77y · Female·Haemoperitoneum following cholecystectomy
A 77-year-old woman died from haemoperitoneum (intra-abdominal bleeding) three days after elective laparoscopic cholecystectomy. Bleeding from the left inferior epigastric artery was a recognised surgical complication bu…
85y · Female·Staphylococcus bacteremia complicating multiple injuries sustained in a motor ve…
An 85-year-old woman sustained multiple serious injuries (bilateral rib and pelvic fractures, thoracic spine fractures) in a motor vehicle collision on 20 June 2018. She was treated with ICU admission, induced coma, and …
63y · Male·metastatic rectal carcinoma
Jeremy Scott, a 63-year-old prisoner, died from metastatic rectal carcinoma on 3 July 2017. From 2015 onwards, he reported rectal and anal symptoms including pain, bleeding, and palpable masses, which were repeatedly att…
56y · Male·Internal blood loss, complications arising from laparoscopic cholecystectomy
Barry Brown, a 56-year-old man, died from internal bleeding after laparoscopic cholecystectomy due to critical systemic failures in post-operative care and diagnosis. Following hypotension at 7:30pm, nursing staff failed…
68y · Male·surgical complications following laparoscopic cholecystectomy for cholecystitis,…
Cyril Churchill, a 68-year-old man with multiple comorbidities, died from surgical complications after laparoscopic cholecystectomy for acute cholecystitis. Postoperatively, he developed profound hypotension. The treatin…
68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…
Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mi…
51y · Female·community acquired pneumonia
Louise Kitty Whiskey, a 51-year-old Aboriginal woman with chronic alcohol misuse, cirrhosis, and recurrent respiratory infections, died from community-acquired pneumonia at Royal Adelaide Hospital. She was admitted on 23…
65y · Male·ischaemic and hypertensive heart disease with contributing acute cholecystitis (…
A 65-year-old man with hypertension presented with acute cholecystitis, underwent laparoscopic cholecystectomy, and initially recovered well. On post-operative day 7, he experienced chest pain radiating to his jaw. Two E…
91y · Male·Complications following cardiac arrest in the setting of anaesthetic induction d…
A 91-year-old man with COPD, asthma, and previous cardiac arrest from suxamethonium died from complications following anaphylaxis to rocuronium during anaesthetic induction for emergency small bowel obstruction surgery. …
93y · Male·Multisystem failure complicating sepsis secondary to perforated viscus
Ward Harker, 93 years old, died in the Alfred Hospital on 1 December 2015 from multisystem failure complicating sepsis following a perforated bowel. He was receiving palliative care. His grandson, Angus Tye, told nursing…
76y · Male·Sepsis due to pulmonary valve endocarditis and cardiac abscess due to Staphyloco…
A 76-year-old man died from sepsis caused by Staphylococcus aureus endocarditis and cardiac abscess. An intravenous cannula inserted during day surgery on 29 November 2018 was not removed before discharge, despite hospit…
71y · Female·pneumonia following cervical spine fracture sustained in motor vehicle collision
Julie Anne Holmes, aged 71, died of pneumonia following a cervical spine fracture sustained in a motor vehicle accident that was not diagnosed during her hospital admission. Critical clinical lessons include: (1) paramed…
53y · Male·aspiration pneumonia on a background of oesophageal cancer and ischaemic heart d…
Anthony Stephen Gibson, aged 53, died in hospital from aspiration pneumonia secondary to oesophageal cancer and ischaemic heart disease. He was serving a prison sentence and was shackled to his bed throughout most of his…
57y · Male·Small bowel perforation complicating small bowel obstruction arising from intra-…
Agostino Cutugno, a 57-year-old prisoner with intellectual disability (IQ 55) and history of self-inflicted abdominal stab wounds, died from small bowel perforation complicating obstruction due to intra-abdominal adhesio…
70y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …
Ali Djawas, a 70-year-old Indonesian-born man with comorbidities (hypertension, diabetes, COPD), underwent elective right hemicolectomy on 13 March 2017 for a suspicious ileo-caecal lesion. Biopsies were benign, CT imagi…
47y · Female·hypoxic encephalopathy and aspiration pneumonia following aspiration of gastric …
Jodie Ann Pearson, aged 47, died from hypoxic encephalopathy and aspiration pneumonia following aspiration of gastric contents during a gastroscopy at Belmont Hospital on 15 February 2016. Critical pre-procedure informat…
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