66 results
8y · Female·renal failure due to focal segmental glomerulosclerosis
A child with complex neurodevelopmental conditions (cerebral palsy/Rett Syndrome) and focal segmental glomerulosclerosis developed progressive renal failure and died at home on palliative care. The coroner found the medi…
16y · Male·pulmonary embolism secondary to nephrotic syndrome
Dylan Riley, a 16-year-old with steroid-responsive minimal change nephrotic syndrome, died from a massive pulmonary embolism (PE) on 1 August 2015. He presented to Rockingham Hospital with dyspnoea, hypoxia, tachycardia …
59y · Male·ischaemic heart disease in the context of acute-on-chronic kidney failure associ…
Arthur James Bonney, a 59-year-old prisoner with advanced cardiac disease, chronic kidney disease, and diabetes, underwent a CT scan with iodinated contrast on 30 July 2015 at Fiona Stanley Hospital. Critical failures oc…
80y · Male·Bronchopneumonia complicating terminal palliative care in an elderly man with ch…
Aurelio Monterlegre Cruz, an 80-year-old man with complex medical conditions including chronic renal failure, ischaemic heart disease, diabetes, and COPD, died of bronchopneumonia complicating terminal palliative care wh…
22y · Male·acute blood loss from incised injuries to left forearm
Simon Smith, a 22-year-old with end-stage renal failure requiring dialysis and complex comorbidities, died by suicide during hospitalization. Despite multiple psychiatric assessments finding he had capacity to make treat…
55y · Male·probable sepsis in the setting of immunosuppression, a skin wound and chronic di…
David Paul Unwin, a 55-year-old kidney transplant recipient with polycystic kidney disease, died of sepsis in January 2017. He presented with progressive symptoms including chronic diarrhoea, weight loss (16kg in 8 weeks…
51y · Male·Exsanguination during home haemodialysis in a man with end stage renal failure
A 51-year-old man with end-stage renal failure died from exsanguination during home haemodialysis. The most likely cause was a procedural error where Mr O'Dwyer connected his dialysis machine's venous line to the venous …
77y · Male·Complications of methotrexate toxicity in a man with chronic renal impairment, c…
A 77-year-old man with chronic kidney disease, COPD, and mild cardiac failure died from methotrexate toxicity after a GP prescribed it at an inappropriate daily dose (5mg daily) for psoriasis without baseline blood tests…
50y · Male·Head injuries due to motor vehicle accident
A 50-year-old traffic controller was struck and killed by a motor vehicle driven by a woman with multiple serious medical conditions (end-stage renal disease, multiple myeloma) who was taking Panadeine Forte. The driver …
71y · Male·cardiac arrest due to hyperkalemia due to acute on chronic renal failure, with r…
John Bell, a 71-year-old man with history of bowel cancer, ischaemic heart disease, and chronic renal failure, underwent elective ileostomy reversal surgery. He died from cardiac arrest due to hyperkalemia and metabolic …
86y · Male·Aspiration Pneumonia secondary to Recurrent Colorectal Carcinoma
An 86-year-old man died from aspiration pneumonia following bowel preparation for elective colonoscopy. He was admitted to an outlying ward rather than the gastroenterology unit, where nursing staff documented multiple e…
79y · Female·Rhabdomyolysis in a woman with multiple myeloma and renal impairment
Margaret Ann Yeomans, aged 79, died from rhabdomyolysis in the context of multiple myeloma and chronic renal impairment. A critical medication error occurred when rosuvastatin 40mg was dispensed instead of her prescribed…
59y · Female·Multiorgan failure and polymicrobial sepsis secondary to severe bone marrow fail…
A 59-year-old woman with renal transplant died from multiorgan failure and sepsis secondary to severe bone marrow failure caused by azathioprine toxicity. She had an undiagnosed genetic polymorphism (TPMT *3A/*3A homozyg…
57y · Female·Haemothorax following acute thoracic aortic dissection in a woman with congenita…
Sally Hopwood, 57, with Turner syndrome, coarctation of the aorta, and bicuspid aortic valve, presented to ED on 23 March 2012 with severe acute back and chest pain (8/10). A chest X-ray revealed widened mediastinum. She…
75y · Female·pyelonephritis and pneumonia
Molly Jessie Smith, a 75-year-old woman with longstanding severe mental illness, died of pyelonephritis and pneumonia on 16 August 2009. She had been in state psychiatric care continuously for 53 years. During her final …
76y · Female·Acute renal failure due to dehydration due to upper gastrointestinal bleed
A 76-year-old woman with chronic pain was admitted to a small rural hospital on 1 April 2015 with haematemesis secondary to NSAID use. Blood tests were ordered on admission but not transported to the district hospital fo…
73y · Female·Multiple organ failure due to or as a consequence of sepsis due to or as a conse…
73-year-old woman died 12 days after elective colorectal surgery for synchronous caecal and rectal tumours. Post-operatively, she developed persistent low urine output and intermittent hypotension managed with repeated f…
80y · Female·Gas embolism complicating surgical repair of an atherosclerotic aortic aneurysm …
An 80-year-old woman with multiple comorbidities (COPD, renal impairment, cardiac disease) underwent complex endoluminal repair of a thoracoabdominal aortic aneurysm at a private hospital. The procedure required use of C…
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…
87y · Male·Strangulated small bowel due to adhesions from previous abdominal surgery
An 87-year-old man with diabetes, hypertension and dementia was admitted with presumed UTI and dehydration. Within 24 hours, nursing staff observed a distended abdomen and bile-stained vomiting—clinical signs of bowel ob…
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