48 results
38y · Female·Pulmonary Thromboembolism
Kellie Anne Keogh, 38, died from pulmonary thromboembolism on 10 November 2008 after complex pancreatic surgery. She had nephrotic syndrome with decreased anti-thrombin III levels, initially presenting with suspected DVT…
69y · Male·Head injury post-collapse secondary to ventricular tachycardia due to ischaemic …
Mr Peysack, a 69-year-old with complex cardiac disease on Warfarin, collapsed at work with witnessed loss of consciousness and occipital laceration. Despite meeting criteria for urgent head CT imaging (age >65, head inju…
77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…
77-year-old male died from complications of haemothorax and hypotension following drainage of pleural effusion post-coronary bypass surgery, in the setting of pre-existing renal impairment and diabetes. During pleural ta…
74y · Male·cardiac and renal failure complicating treatment of infected ischaemic toes resu…
Glenn Howard Raphael, 74-year-old admitted for infected ischaemic toe secondary to diabetes mellitus. During his 17-day hospital stay, he developed acute renal failure leading to cardiac arrest and death. Critical failur…
34y · Male·extensive blood loss from acute gastric erosions following severe scalding of th…
Neil Summerell, a 34-year-old man with intellectual disability, epilepsy, and vision/hearing impairment, died from acute gastric erosions following severe scalding injuries sustained on 29 November 1999. He was scalded t…
67y · Male·acute renal failure with associated severe acidosis and hyperkalemia
A 67-year-old Aboriginal male with dementia was discharged from Royal Darwin Hospital on 4 November 2001 following cystoscopy and bladder neck incision for suspected obstruction. Critical communication failures meant the…
74y · Male·disseminated carcinoma (widespread cancer); specifically haemorrhage into right …
Ronald Smallwood, a 74-year-old man with chronic paranoid schizophrenia and renal cancer, died in hospital from disseminated carcinoma. The key clinical lesson relates to institutional knowledge rather than direct patien…
66y · Male·Complications of chronic lithium therapy
Sydney Kennedy, a 66-year-old man with intellectual disability and bipolar affective disorder, died from complications of chronic lithium therapy. He had been on lithium for years with annual psychiatric review, but ther…
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