240 results
0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the sett…
Mia Rose Iskander died at 8 hours of age from ascending uterine infection (Klebsiella pneumoniae) with chorioamnionitis following maternal premature pre-labour rupture of membranes (PPROM) at 32 weeks. Maternal managemen…
0y · Unknown·unascertained
A 10-day-old neonate born at 36 weeks gestation presented to hospital with signs of sepsis including hypothermia, lethargy, poor feeding, and jaundice. Critical failures in recognition and triage occurred: the infant was…
40y · Male·Acute hepatic and renal failure in the setting of postoperative haemorrhage foll…
A 40-year-old man with obesity, COPD, diabetes and hypertension died from acute hepatic and renal failure following postoperative haemorrhage after left radical nephrectomy for a 10cm renal cell carcinoma. The surgeon ap…
73y · Female·Multi organ failure due to adhesions related bowel perforation (surgically treat…
Sharyn Kaine, a 73-year-old woman, died from multi-organ failure due to adhesions-related bowel perforation and paracetamol-induced liver failure. She was prescribed intravenous paracetamol 1g four times daily post-opera…
16y · Male·mid-gut volvulus and bowel obstruction, leading to ischaemic bowel and related c…
Finlay Browne, a 16-year-old with Down syndrome, presented to Bathurst Base Hospital on 30 September 2016 with acute abdominal pain and vomiting. Despite clear clinical signs—including a lactate of 7.2 mmol/L (grossly ab…
0y · Male·multifactorial with severe hypoxia/hypotension which occurred in the background …
Everett Carleton died at birth following an emergency caesarean section complicated by unexpected placenta praevia and umbilical cord transection. The placenta was incorrectly reported as posterior on ultrasound, though …
17y · Male·stroke (left middle cerebral artery infarction) following motorbike collision du…
Kane Mathew Leary, 17, died from a stroke (left middle cerebral artery infarction) following a motorbike collision. The critical clinical lesson involves a missed diagnosis of left internal carotid artery dissection on i…
70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia
70-year-old Sean Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner identified multiple significant failing…
46y · Male·sepsis following haemorrhoidectomy
46-year-old Justin Mark Dobson died from sepsis following a routine haemorrhoidectomy on 17 July 2019. He was discharged to the ward overnight but deteriorated significantly from 11:00 am on 18 July, showing hypotension,…
59y · Female·Asphyxial aspiration with upper airways obstruction by vomitus
Ms Prenc, a 59-year-old woman with spina bifida, died from asphyxial aspiration with upper airway obstruction by vomitus while hospitalised for urosepsis. The critical clinical issue was a Goals of Care (GOC) document co…
54y · Male·Hypoxic/ischaemic brain damage caused by blood loss and airway obstruction due t…
A 54-year-old male was assaulted in a nightclub with a single punch causing orbital and facial fractures and posterior epistaxis. He presented to the Royal Hobart Hospital ED with active bleeding. Critical deficits in hi…
20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…
Adam Fitzpatrick, a 20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged…
2y · Unknown·Hypoxic-ischaemic encephalopathy following sepsis related to abdominal surgical …
BCT was a 2-year-old Aboriginal child with complex needs from a genetic disorder (CAMTA1 mutation) who died from hypoxic-ischaemic encephalopathy following sepsis related to bowel perforation after a percutaneous endosco…
68y · Female·Pulmonary embolism due to deep venous thrombosis secondary to fractured left dis…
Mary Morrow, aged 68, died from pulmonary embolism and deep vein thrombosis following a fractured left ankle sustained in Queensland on 23 June 2021. She received appropriate VTE prophylaxis initially (enoxaparin) but th…
0y · Female·Fetal demise due to placental abruption and sepsis secondary to chorioamnionitis…
Ashlee Reindl died hours after birth in 2019 following a prolonged induction of labour complicated by fetal distress and chorioamnionitis. A catastrophic placental abruption occurred shortly before emergency caesarean se…
61y · Female·Diffuse alveolar damage in a woman with restrictive lung disease following catar…
A 61-year-old woman with severe restrictive lung disease, obesity, cardiac failure, and diabetes underwent cataract surgery at a private day surgery centre on 13 August 2018. She was unable to lie flat and became hypoxic…
2y · Female·perforated oesophagus secondary to complications of treatment of oesophageal inj…
Callie Griffiths-I'Anson, a 2-year-old girl, died from a perforated oesophagus secondary to complications of treatment for caustic soda ingestion. She ingested caustic dishwashing liquid at a hotel on 11 December 2017 an…
79y · Male·complications of peritonitis
A 79-year-old man with multiple comorbidities presented with a perforated bowel requiring emergency Hartmann's procedure. The operating surgeon, Dr Liu-Ming Schmidt, made a catastrophic surgical error by exteriorising th…
67y · Female·Intra-abdominal sepsis complicating an anastomotic leak following elective surge…
A 67-year-old woman died from intra-abdominal sepsis following an anastomotic leak from elective colorectal surgery to repair a vesico-colic fistula. The initial surgery on 1 November 2017 was appropriately performed, an…
64y · Male·Peritonitis, due to or as a consequence of a ruptured gallbladder, due to or as …
Dennis Childs, a 64-year-old Indigenous man serving a life sentence, died from peritonitis secondary to a ruptured gallbladder. On 8 December 2018, he presented with abdominal pain at the correctional centre but refused …
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