130 results
77y · Female·Complications following a recent fracture and surgical repair of the right hip i…
A 77-year-old woman with complex comorbidities (atrial fibrillation, aortic stenosis, chronic renal impairment, emphysema) on Warfarin sustained a femur fracture and underwent ORIF on day 3 of admission (19 Nov 2009). Ke…
83y · Female·neck compression from a wheelchair restraint strap
Ruth Ann Dicker, an 83-year-old resident of an aged care facility with epilepsy, Parkinson's disease, and dementia, died from neck compression caused by a wheelchair lap belt restraint. After a significant history of fal…
82y · Female·fat embolism syndrome and bronchopneumonia following nail fixation of bilateral …
An 82-year-old woman with severe dementia and marked osteoporosis died from fat embolism syndrome and bronchopneumonia following surgical fixation of bilateral femoral fractures. The fractures occurred on 10 September 20…
84y · Male·respiratory failure due to hospital-acquired pneumonia
Ronald Geoffrey Weeks, aged 84, died of respiratory failure due to hospital-acquired pneumonia following a hip fracture sustained in a fall at James Nash House psychiatric facility. He was serving an 8-year sentence for …
64y · Male·hypoxic-ischaemic encephalopathy complicating cardiac arrest due to retroperiton…
A 64-year-old man died from hypovolaemic cardiac arrest caused by retroperitoneal bleeding from a pelvic fracture. The bleeding occurred six days post-injury while on high-dose enoxaparin (100mg twice daily) initiated un…
12y · Male·Head injuries resulting from ride-on mower collision
Jake Garrett-Pratt, a 12-year-old boy, died from fatal head injuries sustained when he lost control of a poorly maintained ride-on lawn mower on a steep driveway. The rear axle drive chain broke due to inadequate mainten…
88y · Female·pulmonary thromboembolism due to fractured right femur due to a fall
Cynthia Thoresen, 88-year-old woman with dementia and osteoporosis, fell at home and sustained a fractured femur approximately three weeks before admission. Her daughter, the registered carer, failed to seek medical atte…
21y · Male·Acute hypoxic ischaemic encephalopathy and pneumonia in a man with recent trauma…
Peter Martin Carroll, age 21, died on 8 June 2007 in the ICU at Royal Perth Hospital from acute hypoxic ischaemic encephalopathy and pneumonia following oxycodone overdose. He had been discharged that day (5 June) after …
83y · Female·Diffuse Alveolar Damage in a woman with recent leg fracture and Atherosclerotic …
An 83-year-old woman with diabetes, cardiovascular disease, and mobility limitations fell from her bed while on a bedpan at an aged care facility, sustaining a compound ankle fracture. The registered nurse on duty had le…
47y · Male·Aspiration pneumonia due to or as a consequence of coronary atherosclerosis
Christopher Hammett, a fit 47-year-old, died from aspiration pneumonia with contributing coronary atherosclerosis following routine L5-S1 disc replacement. A critical oxygen desaturation (64%) occurred during transfer fr…
86y · Male·coronary and cerebral atherosclerosis with significant conditions of fractured l…
Mr. Stanley Charles Anderson, aged 86, died at Gympie General Hospital from coronary and cerebral atherosclerosis, precipitated by injuries sustained in a fall at a nursing home. While transferring from a bath trolley to…
76y · Female·Aspiration pneumonia complicating surgery for pelvic and spinal fractures on a b…
A 76-year-old woman died from aspiration pneumonia following surgery for pelvic and spinal fractures sustained in a fall on a shopping centre travelator. She fell when her husband lost control of a shopping trolley with …
45y · Male·Hypoxic-ischaemic encephalopathy due to prolonged hypoxia
A 45-year-old man died from hypoxic-ischaemic encephalopathy following cardiopulmonary arrest 11 hours after elective wrist plate removal surgery. Multiple contributing factors were identified: undisclosed obstructive sl…
42y · Male·Pulmonary thromboembolism and deep calf vein thrombosis
Shane Kerstjens, a 42-year-old man with cerebellar dystrophy and intellectual disability, died from pulmonary thromboembolism and deep vein thrombosis. He sustained a tibia and fibula fracture on 6 September 2007, requir…
12y · Female·Raised intracranial pressure due to acute-on-chronic hydrocephalus in the contex…
Samantha Rose Spence, 12 years old, died two days after spinal fusion surgery for severe scoliosis. She had a pre-existing, asymptomatic Chiari type 1 malformation detected on pre-operative MRI of her spine. A paediatric…
55y · Male·Multiple injuries sustained in a fall
Patrick Tolan, a 55-year-old man with chronic depression, alcohol dependence, and multiple suicide attempts, died from injuries sustained in a fall from a shopping centre sign. He had jumped from a parapet four years ear…
12y · Female·acute septicaemia resulting from osteomyelitis of the left femur
A 12-year-old Aboriginal girl died from septicaemia caused by untreated osteomyelitis of the left femur. Three weeks after a sports injury, despite evidence of severe and deteriorating illness including inability to walk…
82y · Female·acute peritonitis, ruptured bowel and incarcerated bowel herniation
An 82-year-old woman admitted with bowel obstruction recovered well initially but suffered a preventable fall in the radiology department when left unattended with heavy IV pumps on her wheelchair, fracturing her hip. Af…
57y · Female·acute pulmonary embolism
Sandra McRae, age 57, died from pulmonary embolism on day 13 of hospitalisation following pelvic fractures sustained in a motor vehicle accident. The coroner found the death was potentially preventable due to failure to …
28y · Male·hypovolemia secondary to haemorrhage from operative exploration of multiple stab…
A 28-year-old Aboriginal male died from hypovolemic shock following operative exploration of multiple stab wounds to the thigh. The death was preventable. Critical failures included: delayed surgery from Friday to Saturd…
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