259 results
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…
89y · Female·Aspiration pneumonia complicating electroconvulsive therapy for treatment of psy…
Hilda Berg, 89-year-old woman with depression, psychosis, atrial fibrillation, chronic kidney disease and type 2 diabetes, deteriorated in hospital with refusal to eat or drink due to psychotic beliefs. After initial con…
49y · Female·hypoxic ischaemic encephalopathy complicating cardiac arrest due to pulmonary th…
A 49-year-old woman with morbid obesity, obstructive sleep apnoea, and psychiatric history was admitted following deliberate medication overdose. She was intubated, managed in ICU, then transferred to the ward where she …
18y · Female·Multiorgan failure complicating malnutrition in a female with liver cirrhosis, o…
An 18-year-old female with Down syndrome, autism spectrum disorder, and severe intellectual disability died from multiorgan failure complicating severe malnutrition, non-alcoholic fatty liver disease, and obesity. She pr…
48y · Male·Septicaemia in a man with a psoas abscess; Diabetes mellitis
A 48-year-old man with insulin-dependent diabetes, mild cognitive impairment, and chronic alcoholic liver disease was admitted with sepsis from a psoas abscess. After 15 days of intravenous antibiotics, he refused IV con…
51y · Male·pulmonary thromboembolus secondary to left deep vein thrombosis
Darren Templeton, a 51-year-old man with obesity (BMI 31.5), died of pulmonary thromboembolism and left deep vein thrombosis six days after undergoing left knee arthroscopy. Critical clinical lessons: (1) VTE risk assess…
83y · Female·upper gastrointestinal bleed with haemodynamic compromise following anticoagulat…
Margaret Patricia Kenney, 83, died from upper gastrointestinal bleeding complicated by cardiac arrest while anticoagulated for atrial fibrillation. She had been diagnosed with gastro-oesophageal reflux disease (GORD) in …
78y · Female·Complications arising from a left femur fracture following an unwitnessed fall i…
Doreen Mansfield, a 78-year-old woman with bipolar affective disorder managed with lithium and ECT, was admitted to the Royal Hobart Hospital under a Mental Health Act treatment order. She sustained an unwitnessed fall i…
96y · Female·Pseudomonas aeruginosa sepsis secondary to infected leg ulcers, complicated by m…
A 96-year-old woman with diabetes, dementia and a chronic blistering skin condition developed progressively worsening leg ulcers with exposed tendons while resident in an aged care facility. Despite multiple medical revi…
pneumonia
Yvonne Dawn Cohen died of pneumonia six days after discharge from North West Regional Hospital. She had been admitted twice for abdominal pain, vomiting and diarrhoea. The coroner found that clinical care fell short of a…
75y · Male·Right haemothorax complicating intercostal catheter insertion for the treatment …
Giuseppe Costa, 75, died from right haemothorax following intercostal catheter insertion for pleural effusion drainage. Critical failures in clinical management included: inadequate documentation of pleural fluid drainag…
82y · Male·Cardiomegaly, myocardial fibrosis and ischaemic coronary artery disease in the c…
An 82-year-old man with extensive comorbidities underwent colonoscopy with argon plasma coagulation (APC) for bleeding angiodysplasia. Prolonged activation intervals during the final third of the procedure caused full-th…
28y · Female·aspiration of gastric contents complicating laxative abuse
A 28-year-old woman died from aspiration of gastric contents complicating severe laxative abuse. She fabricated a terminal cancer diagnosis to conceal anorexia nervosa and factitious disorder. During a RAH admission, a C…
41y · Male·Cerebral hypoxia and bronchopneumonia; contributing factors: toxic megacolon, ce…
David Orton, a 41-year-old man with cerebral palsy, intellectual disability, and severe kyphoscoliosis, died from cerebral hypoxia and bronchopneumonia complicated by toxic megacolon and Salmonella infection. Over 18 mon…
61y · Male·exposure and dehydration, preceded by alcohol withdrawal and chronic alcoholism
A 61-year-old man with chronic alcoholism was admitted to hospital for alcohol withdrawal management. He became confused and paranoid on the ward, received appropriate medication, but left hospital unobserved approximate…
81y · Male·aspiration of gastric contents complicating disseminated moderately differentiat…
Graham Joseph Butson, aged 81, died from aspiration of gastric contents complicating undiagnosed metastatic lung cancer with brain metastases. He presented with confusion, agitation and atrial fibrillation; a lung mass w…
41y · Male·large volume thrombotic stroke within the distribution of the right posterior ce…
A 41-year-old man with acute posterior circulation stroke was misdiagnosed as encephalitis despite normal lumbar puncture findings. The critical failure was Dr R.'s failure to diagnose stroke on 7 September and arrange u…
52y · Male·Intracerebral haemorrhage
A 52-year-old man in remand custody at Port Phillip Prison was diagnosed with moderate hypertension in June 2015 and commenced on Ramipril. He experienced two periods of non-compliance with medication (July-August and Se…
69y · Male·septic shock due to infected decubitus ulcers complicated by osteomyelitis
A 69-year-old man with Parkinson's disease died from septic shock caused by infected pressure ulcers (stage 4 decubitus ulcers with osteomyelitis) that developed in aged care. Pressure sores appeared within 31 days of ad…
83y · Female·Hyponatraemic encephalopathy due to adverse effects of citaprolam and duloxetine…
An 83-year-old woman with pre-existing SIADH-related chronic hyponatraemia died from hyponatraemic encephalopathy following antidepressant therapy. Critical clinical lessons include: (1) the importance of accessing prior…
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