52 results
76y · Male·Chest sepsis in a man with ischaemic heart disease
A 76-year-old man with multiple myeloma and complex medical history died from chest sepsis and myocardial infarction following a medication dispensing error. After discharge from hospital for spinal compression fractures…
72y · Male·Diffuse large B cell lymphoma
Douglas Stott, a 72-year-old prisoner with diffuse large B cell lymphoma, died of natural causes in hospital on 7 January 2021. He had been receiving telehealth oncology consultations while incarcerated but refused in-pe…
59y · Female·Sepsis in a woman with epilepsy, cerebral palsy and haemochromatosis
A 59-year-old woman with cerebral palsy, epilepsy, and intellectual disability died of sepsis from a urinary tract infection (urosepsis) caused by E. coli and Proteus mirabilis. She had four hospital presentations in the…
57y · Female·Pulmonary thromboembolism
Ann-Maree Manno, 57, died from pulmonary thromboembolism 8 days after laparoscopic gastric band surgery. She had significant risk factors: obesity (BMI 37.9), history of unprovoked DVT in 2007 and 2016, and recent surger…
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…
64y · Male·Left-sided intracerebral haemorrhage associated with deep brain stimulator wire …
A 64-year-old man died from intracerebral haemorrhage along a deep brain stimulator wire tract four days after elective neurosurgery for essential tremor. He was readmitted on day 4 with suspected stroke and started on t…
21y · Female·pulmonary embolism in association with deep vein thrombosis of the left leg
A 21-year-old woman died from pulmonary embolism associated with deep vein thrombosis following ankle fracture surgery and immobilisation. She was discharged without thromboprophylaxis despite multiple VTE risk factors (…
5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …
A five-year-old child with complex neurodevelopmental conditions and polypharmacy (including valproic acid for epilepsy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with ora…
85y · Female·sepsis, with aspiration pneumonitis being an antecedent cause. Iatrogenic injury…
Lorraine Barnes, an 85-year-old woman admitted to Wollongong Private Hospital for convalescence, died from sepsis with aspiration pneumonitis following iatrogenic lung injury. She developed severe malnutrition and electr…
76y · Male·Intracranial Haemorrhage Secondary to Blunt Head Trauma (Fall) in the Setting of…
A 76-year-old man with newly diagnosed chronic myeloid leukaemia in blast crisis was admitted to hospital with sepsis and pancytopenia from chemotherapy. He suffered multiple falls while confused from sepsis, sustaining …
35y · Female·Unascertained
A 35-year-old grand multipara with multiple risk factors (BMI >35, smoking, grand multiparity, pregnancy-induced hypertension) presented at 40+4 weeks with absent foetal movements and was induced on Sunday evening. She e…
50y · Male·Head injuries due to motor vehicle accident
A 50-year-old traffic controller was struck and killed by a motor vehicle driven by a woman with multiple serious medical conditions (end-stage renal disease, multiple myeloma) who was taking Panadeine Forte. The driver …
Unknown·Acute myeloid leukaemia (AML)
Four patients with acute myeloid leukaemia (AML) died following administration of chemotherapy consolidation therapy that was delivered according to a protocol containing a critical error—specifying once-daily instead of…
acute myeloid leukaemia
Four patients with acute myeloid leukaemia died after receiving chemotherapy consolidation therapy that was administered once daily instead of the intended twice daily schedule due to a protocol error. The error originat…
58y · Male·Complications of chemotherapy for the treatment of Hodgkin lymphoma
Mettaloka Halwala, 58, died from complications of bleomycin toxicity during Hodgkin lymphoma chemotherapy. A PET scan on 11 November 2015 showed widespread lung uptake suggestive of bleomycin pneumonitis, but the haemato…
79y · Female·Rhabdomyolysis in a woman with multiple myeloma and renal impairment
Margaret Ann Yeomans, aged 79, died from rhabdomyolysis in the context of multiple myeloma and chronic renal impairment. A critical medication error occurred when rosuvastatin 40mg was dispensed instead of her prescribed…
50y · Male·Multiple pulmonary thromboemboli due to deep vein thrombosis following pharyngea…
A 50-year-old man died from pulmonary thromboembolism following uvulopalatopharyngoplasty (UPPP) surgery for obstructive sleep apnoea. Critical failures in post-operative management at a private hospital included: failur…
59y · Female·Multiorgan failure and polymicrobial sepsis secondary to severe bone marrow fail…
A 59-year-old woman with renal transplant died from multiorgan failure and sepsis secondary to severe bone marrow failure caused by azathioprine toxicity. She had an undiagnosed genetic polymorphism (TPMT *3A/*3A homozyg…
58y · Female·Haemorrhagic shock complicating pulmonary thromboembolism in the setting of deep…
A 58-year-old woman with obesity (BMI 38) sustained a metatarsal fracture and was treated with a below-knee plaster cast by her GP. Despite appropriate initial assessment and consultation with a haematologist regarding V…
77y · Male·Complications of reaction to an iron infusion in a man with ischaemic heart dise…
A 77-year-old man with iron deficiency anaemia and underlying ischaemic heart disease died from anaphylaxis following iron polymaltose infusion. Critical clinical lessons: (1) IV iron should only be administered after or…
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