136 results
15y · Male·Multiple organ failure associated with hyperthermia (heat stroke)
A 15-year-old rugby league player died from heat stroke during training on an extremely hot Perth summer evening (44.4°C). The coaching staff appropriately applied NRL heat guidelines in deciding to proceed with modified…
24y · Male·seizure (epileptic)
Mohammad Nasim Najafi, a 24-year-old Afghan detainee with well-controlled epilepsy, died from a seizure after missing multiple doses of carbamazepine in the days preceding his death. He was held in immigration detention …
Unknown·Michael Russell: intracranial haemorrhage complicating surgery for right cerebra…
Two patients died following stroke interventions on 18 April 2017 at the Royal Adelaide Hospital. Michael Russell (60) died from intracranial haemorrhage following vessel perforation during thrombectomy for acute coronar…
53y · Male·fentanyl and oxycodone toxicity
Stephen Robert Atkins, 53, died from fentanyl and oxycodone toxicity after admission to Flinders Medical Centre for investigation of Horner's syndrome and radiculopathy. Over three days, escalating opioid doses were pres…
72y · Female·Obstruction of the airways of the neck
A 72-year-old woman with moderate-severe expressive and receptive dysphasia following an acute left middle cerebral artery stroke died by hanging three months post-discharge from rehabilitation. Critical deficiencies wer…
63y · Female·disseminated metastatic carcinoma of unknown primary in a woman with multiple sc…
Pamella Rees, a 63-year-old woman with longstanding multiple sclerosis, died on 30 June 2014 from disseminated metastatic carcinoma of unknown primary. Her cancer went undiagnosed despite regular GP contact. In her final…
0y · Male·complications of head injury
A premature newborn died from severe head injuries inflicted deliberately by his teenage father in hospital on 15 February 2014. The father had a well-documented history of violence, substance abuse, criminality and had …
41y · Male·Sudden unexpected death in epilepsy (SUDEP)
Rohan Grindrod, a 41-year-old man with acquired brain injury and epilepsy following a 2007 motor vehicle accident, died of Sudden Unexpected Death in Epilepsy (SUDEP) at his home on 16-17 November 2011. He had a Personal…
53y · Male·Choking on food bolus in pharynx, with Huntington's disease and coronary atheros…
Paul Joseph Milward, aged 53 with Huntington's disease causing cognitive impairment and swallowing difficulties, died from choking on a bread sandwich while unsupervised in his aged care room. His care plan specified min…
5y · Male·complications of blunt force injury to the head
A 5-year-old boy died from complications of blunt force head injury sustained on 19-20 March 2010. He presented to a rural hospital unresponsive, with the initial account not mentioning head trauma. The attending doctor …
Unknown·acute fentanyl toxicity; acute oxycodone toxicity; multiple drug toxicity; opioi…
Four adults died from opioid overdoses (fentanyl and oxycodone) in Queensland between 2012–2014. All obtained prescriptions from multiple doctors ('doctor shopping') without effective detection. Systemic failures include…
28y · Female·complications of epilepsy
Carney Schultz, a 28-year-old woman with severe cerebral palsy, hydrocephalus, and epilepsy, died on 21 April 2015 at a group home. She experienced a seizure around 3:20am managed by a disability support worker (DSW) wit…
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 Reben's failure to diagnose stroke on 7 September and arrang…
57y · Male·large volume ischaemic infarct (stroke)
Stephen John French, a 57-year-old with prior stroke (2002) and myocardial infarction (2009), presented with headache, visual disturbance and gait difficulty in May 2013. Imaging at Launceston General Hospital on 30 May …
59y · Female·Global cerebral oedema due to hypoxic cerebral ischaemia following cardiac arres…
59-year-old woman admitted with newly diagnosed grade 4 glioblastoma underwent surgery 16 days later after delays during consultant's planned leave. Post-operative complications included ischaemic stroke confirmed on ima…
41y · Female·Left middle cerebral artery territory ischaemic stroke
A 41-year-old registered nurse presented to the Emergency Department with altered consciousness on 28 May 2015. She was initially assessed as having a possible medication overdose rather than acute stroke, despite later …
21y · Female·Hypoxic ischaemic encephalopathy following unexplained cardiac arrest
A 21-month-old Aboriginal child in DCP care died from hypoxic ischaemic encephalopathy following unexplained cardiac arrest. The child showed progressive withdrawal and received multiple minor injuries over two months. O…
0y · Female·Group B Streptococcus meningitis and sepsis
An 18-day-old baby died from late-onset Group B Streptococcus (GBS) meningitis and sepsis. She was born at a regional private hospital after labour complicated by maternal fever (37.6°C), foetal tachycardia (160-170 bpm)…
46y · Female·Prolonged effects and complications of a head injury, with upper airway obstruct…
Helen Ashburn, a 46-year-old woman with history of alcohol use, coagulopathy and seizures, died from prolonged effects of a severe head injury sustained on 25 October 2011. She presented to Kempsey Hospital with extensiv…
48y · Female·Sepsis due to pulmonary and cutaneous infections, with urinary tract infection a…
A 48-year-old tetraplegic woman died from sepsis originating from a necrotic sacral pressure wound. Multiple system failures contributed: inadequate pressure sore prevention at the disability care provider (air mattress …
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