71 results
75y · Male·multifactorial causes on a background of ischaemic heart disease, generalised va…
Robert Bischard, a 75-year-old man with multiple complex comorbidities including coronary artery disease, chronic kidney disease, and diabetes, died five days after elective right total knee replacement surgery. The coro…
70y · Male·hypovolaemic shock due to the consequences of fractured femur
Thomas Fulcher, a 70-year-old man with intellectual disability and osteoporosis in a group home, fell on 19 January 2018 and sustained a spiral femur fracture with internal bleeding. Care workers failed to seek medical a…
20y · Female·multi-organ failure due to polypharmacy overdose
A 20-year-old woman with depression and borderline personality disorder died from multi-organ failure following a large polypharmacy overdose (13 grams of paracetamol among 78 tablets). She was admitted to the ED where i…
54y · Male·Bowel ischaemia resulting from acute thrombosis of superior mesenteric artery an…
Anthony Barrett died from bowel ischaemia caused by acute thrombosis of his superior mesenteric artery and coeliac artery stents post-operatively. He had undergone left total knee replacement surgery at Fairfield Hospita…
1y · Female·unrecognised oesophageal intubation
A 19-month-old girl died from unrecognised oesophageal intubation during anaesthesia for finger laceration repair. The anaesthetic team failed to recognise multiple clinical indicators of tube misplacement: absence of pe…
36y · Male·Combined drug toxicity (pregabalin, morphine, amitriptyline)
A 36-year-old motor mechanic with chronic pain from a 2014 knee injury died from combined drug toxicity (pregabalin, morphine, amitriptyline). His general practitioner, Dr Schneider, prescribed excessive amounts of multi…
78y · Female·cardiorespiratory failure, ischaemic and hypertensive heart disease together wit…
Barbara Francis, a 78-year-old resident with dementia at Pearl Supported Care in the dementia unit (Dinah), was punched by another resident (Mr A) on 4 September 2018 and fell backward onto her right hip, sustaining an o…
85y · Female·Multisystem failure complicating ischaemic heart disease and ischaemic bowel in …
Lydia Maxfield, 85, died 5 days after elective left total knee replacement at a private hospital from multisystem failure due to ischaemic heart disease and ischaemic bowel. Critical clinical lessons: (1) Multiple abnorm…
76y · Male·Bronchopneumonia in a man with ischaemic heart disease and treated spinal crush …
John Hayle, a 76-year-old with Alzheimer's dementia, ischaemic heart disease, and spinal fractures sustained a T11/12 flexion-distraction fracture on 9 June 2017. Over three weeks, he developed progressive bilateral lowe…
86y · Female·Sepsis complicating sacral decubitus ulceration in the setting of recent surgica…
Mrs Di Quinzio, an 86-year-old woman with multiple comorbidities, was discharged from hospital to a supported residential service (SRS) after hip fracture surgery. She required two-person assistance for mobility and was …
76y · Male·Hypothermia and multiorgan failure complicating compound left tibia and fibula f…
Leslie Roberts, a 76-year-old man with intellectual disability under DHHS care, died from hypothermia and multiorgan failure following a compound fracture of the left tibia and fibula sustained in a fall at home. He was …
24y · Male·Peritonitis secondary to a perforation of the small bowel
Nicholas Wells, a 24-year-old man, died from peritonitis secondary to small bowel perforation sustained in a motor vehicle accident. Although he was suspected of having a bowel injury at 11am on admission, he was placed …
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…
88y · Female·Sepsis complicated by multiple organ failure in a woman with comorbidities in th…
An 88-year-old woman died from sepsis with multiple organ failure following shoulder surgery. She developed an undiagnosed urinary tract infection after placement of an indwelling catheter. Critical failures included: in…
42y · Male·Cardiac arrest following hypoxic ischaemic encephalopathy, likely due to E.coli …
Jarrod Wright, a 42-year-old man admitted with cellulitis, developed sepsis-related acute respiratory distress syndrome (ARDS) requiring ICU care with non-invasive ventilation. Critical failures occurred in managing his …
84y · Female·left lower lung bronchopneumonia in conjunction with small distal pulmonary embo…
An 84-year-old woman with comorbidities sustained right shoulder and pelvic fractures from an accidental fall. She presented to ED with low oxygen saturation (77%) requiring supplemental oxygen. Despite these injuries an…
73y · Male·Consequences of myocardial infarction with coronary artery atherosclerotic disea…
Leonard Bartholomeusz, aged 73, died of myocardial rupture on 6 May 2013, six days after hip fracture surgery. He suffered a fall on 30 April 2013 following which ECG testing revealed cardiac abnormality. A first ECG at …
54y · Male·aspiration pneumonia caused by multiple drug toxicity
Paul Lau, aged 54, died from aspiration pneumonia caused by opioid toxicity following ACL reconstruction surgery. The death resulted from a prescribing error where anaesthetist Dr K. inadvertently prescribed a 100mcg/hou…
76y · Male·Coronary atherosclerosis in the context of obesity, obstructive sleep apnoea, an…
A 76-year-old man with significant comorbidities including severe obstructive sleep apnoea, obesity, aortic stenosis, and ischaemic heart disease died from acute coronary atherosclerosis 36 hours after elective sacroilia…
73y · Male·Acute intracranial haemorrhage, due to or as a consequence of coagulopathy, due …
Mr Stimpson, a 73-year-old man, died from massive intracerebral haemorrhage secondary to coagulopathy caused by inadvertent double administration of anticoagulants (Clexane and Xarelto). He developed bilateral pulmonary …
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.