2,427 results
87y · Female·Multiple opioid drug toxicity (morphine and fentanyl) in combination with conges…
An 87-year-old woman with multiple comorbidities (ischaemic heart disease, emphysema, chronic kidney disease) was discharged home for palliative care after a hospital admission. Her family administered excessive doses of…
10y · Female·Multi-organ failure secondary to overwhelming herpes simplex virus (HSV) infecti…
A 10-year-old girl died from multi-organ failure secondary to overwhelming herpes simplex virus (HSV) infection. She presented to the Women's and Children's Hospital on day 3 of pharyngitis with ulceration of the tonsill…
0y · Female·Hypoxic-ischaemic encephalopathy in the setting of chronic placental insufficien…
Emma, born 26 July 2011, developed severe hypoxic-ischaemic encephalopathy associated with chronic placental insufficiency and died at 4 days old. Her mother reported reduced foetal movements after 34 weeks' gestation, b…
47y · Female·Multiple injuries from being struck by a train; death determined to be suicide
A 47-year-old woman with bipolar affective disorder and PTSD, originally from Bosnia, died by suicide by stepping in front of a train on 1 May 2012. She was subject to a Community Treatment Order at the time. Critical cl…
48y · Male·sepsis and renal failure due to perforated gastric ulcer
A 48-year-old man with hepatitis C and schizo-affective disorder presented to West Coast District Hospital on 20 October 2014 with severe abdominal pain radiating to the right shoulder tip, generalised tenderness, and a …
73y · Male·Stab wound to the neck
Harold Nolan, 73, was fatally stabbed in the neck by his ex-wife Renee Nolan while asleep at home. Ms Nolan was his full-time carer following his 2013 stroke and was experiencing severe carer fatigue, mental health deter…
29y · Female·peritonitis caused by ischaemia of the bowel due to gastrointestinal torsion (tw…
Shona Hookey, a 29-year-old Aboriginal woman with severe intellectual disability and aphasia, died of peritonitis secondary to bowel torsion. Critical failures occurred at multiple levels: carers at her group home delaye…
0y · Male·Complications of hypoxic ischaemic encephalopathy secondary to recurrent episode…
Kyran Day, a 6-month-old boy, presented to Shoalhaven District Memorial Hospital with vomiting and lethargy on 19 October 2013. He was initially assessed and diagnosed with gastroenteritis based on recent rotavirus vacci…
75y · Male·acute right subdural haemorrhage sustained in a fall
George Triantafilopoulos, a 75-year-old man on warfarin after aortic valve replacement, suffered two head strikes within 24 hours—first falling onto concrete at a supermarket on 14 August 2014, then falling onto concrete…
22y · Female·staphylococcal septicaemia and pneumonia complicating osteomyelitis of a right 1…
Julieka Dhu, a 22-year-old Aboriginal woman, died on 4 August 2014 from staphylococcal septicaemia and pneumonia complicating osteomyelitis of a rib fracture sustained in April 2014. She was detained in police custody on…
58y · Male·blunt force head injury
Frederick Peisley, an Aboriginal man with acquired brain injury and schizoaffective disorder, died from a head injury after falling from stairs at an aged care facility. Critical failures included poor communication of h…
34y · Male·sepsis due to extensive small bowel infarct caused by bowel incarceration within…
Jason Keith Harrison, aged 34, died from sepsis due to extensive small bowel infarction caused by bowel incarceration within a congenital mesenteric hernia. He presented to West Coast District Hospital with epigastric pa…
21y · Male·combined effect of a cocktail of drugs causing central nervous system depression…
Paul Fennessy, a 21-year-old with polysubstance addiction and mental health issues, died from positional asphyxia following a drug overdose on 6 January 2010. He presented to the Emergency Department that afternoon after…
21y · Male·combined effect of a cocktail of drugs taken by him, which caused central nervou…
Paul Fennessy, 21 years old, died from a cocktail of drugs causing central nervous system and respiratory depression with positional asphyxia on 6 January 2010. He had a decade-long history of polysubstance abuse, doctor…
3y · Male·Streptococcus pyogenes group A pneumonia
Hugo Gardiner, a 3-year-old boy with fever, cough, vomiting and diarrhoea, was assessed twice at Mount Beauty Medical Centre on 23 December 2015 by GPs who diagnosed viral upper respiratory tract infection. Both doctors …
60y · Male·Global cerebral ischaemia post cardiac arrest in the setting of neck compression
Joseph Pezzimenti, a 60-year-old involuntary psychiatric patient, died from cerebral ischaemia following hanging by a tracksuit cord in a Low Dependency Unit bathroom. Key clinical lessons include: communication difficul…
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 …
40y · Male·UNDETERMINED - natural causes (most probably natural disease; starvation could n…
Miroslaw Dziczkowski, a 40-year-old man with paranoid schizophrenia managed under a Community Treatment Order, disappeared in January 2013 after withdrawing $7300 and relocating to a caravan park without notifying his me…
47y · Male·Multiple injuries due to or as a consequence of a motor vehicle accident
Trevor Toms, 47, died in a head-on motor vehicle collision after driving at speed on the wrong side of a rural highway. He had epilepsy managed with sodium valproate but had experienced multiple seizures in the months be…
36y · Male·hanging
A 36-year-old man with 15-year history of paranoid schizophrenia and polysubstance abuse presented to hospital after violent behaviour toward his father while intoxicated. Despite police concerns, family requests for adm…
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