26 results
62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (su…
A 62-year-old man died from intraoperative haemorrhage during surgery for a renal tumour initially diagnosed as benign anastomosing haemangioma on biopsy but found at autopsy to be metastatic clear cell renal cell carcin…
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…
76y · Male·metastatic prostate cancer with terminal palliative care
Kevin John Keath, aged 76, died from metastatic prostate cancer while serving a life sentence at Casuarina Prison. He received holistic, compassionate, and appropriate healthcare throughout his incarceration, including r…
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…
75y · Male·complications of metastatic prostate cancer and end-stage chronic obstructive pu…
Frank Kenneth Major, a 75-year-old prisoner with metastatic prostate cancer and end-stage COPD, died of natural causes in October 2021. The coroner found his overall medical care during incarceration was excellent and co…
87y · Male·Metastatic carcinoma of the prostate with complications (end-of-life palliative …
Errol Warren Bartlett-Torr, aged 87, died of metastatic prostate cancer on 20 June 2021 whilst in prison custody and receiving palliative care at Bethesda Hospital. Clinical lessons include: (1) elevated PSA findings sho…
66y · Male·sepsis following bacteraemia caused by transurethral catheter insertion
A 66-year-old man with severe dementia and multiple comorbidities died from sepsis following bacteraemia after a routine indwelling urinary catheter change at a nursing home. The catheter insertion was traumatic, resulti…
63y · Male·acute blood loss due to self-inflicted sharp force incisional wounds of the thro…
A 63-year-old man with multiple chronic conditions including psoriatic arthritis, depression, prostate cancer, and recent dental issues died by self-inflicted sharp force wounds while on approved leave from a mental heal…
58y · Male·Pneumonia and urosepsis
Brent Newman, a 58-year-old man with Down syndrome and early-onset dementia, died from pneumonia and urosepsis following inadequate care at an aged care facility. His indwelling catheter was poorly managed, causing ureth…
71y · Male·Plastic bag asphyxia and argon gas inhalation
A 71-year-old man with metastatic bladder cancer, chronic renal failure, and recent dialysis initiation deliberately ended his life using argon gas inhalation. Over 12 years of progressive cancer treatment, multiple surg…
53y · Female·multiple organ failure as a result of septic shock
Pauline Kessell, aged 53, died from septic shock caused by overwhelming sepsis following endoscopic pyeloscopy with laser lithotripsy for a 5cm infected staghorn calculus on 12 August 2015. Critical clinical lessons: (1)…
48y · Female·Combined toxic effect of prescription and non-prescription medications including…
Lauren Johnstone, aged 48, died from the combined toxic effects of prescription and non-prescription sedative medications including oxycodone, tramadol, codeine, zopiclone, doxylamine and fluoxetine. She had undergone mu…
78y · Male·metastatic malignancy (unknown primary) with contributing right-sided heart fail…
Leonard Edward Dodson, aged 78, died in custody from metastatic liver cancer (unknown primary) with contributing right-sided heart failure. He had prostate cancer diagnosed in 2010 via elevated PSA (20ng/ml) but was not …
76y · Male·multiple organ failure due to large volume aspiration of gastric contents during…
Maurice Nancarrow, 76, died from multiple organ failure following aspiration of gastric contents during anaesthetic induction for cystoscopy on 15 August 2015. He had undergone colorectal surgery on 30 July with complica…
86y · Male·Sepsis with septic shock, due to urinary tract infection, pyelonephritis (kidney…
An 86-year-old man died from sepsis and septic shock secondary to urinary tract infection, pyelonephritis and prostatic infection. He presented to his GP in March 2015 with dizziness and reported urinary incontinence and…
66y · Male·Multi-system failure and ischaemic gut after left nephrectomy complicated by mas…
A 66-year-old man died from multi-system failure and ischaemic bowel following laparoscopic left nephrectomy complicated by massive haemorrhage and vascular injury. During surgery for renal carcinoma, the surgeon attempt…
66y · Male·carcinomatosis complicated by recurrent sepsis and multisystem failure in a man …
A 66-year-old man with renal cell carcinoma died in hospital from carcinomatosis with sepsis and multisystem failure. Critical clinical lesson: haematuria in 2005 was not adequately investigated with imaging despite recu…
48y · Male·myocardial infarction due to ischaemic heart disease due to hypertension
A 48-year-old man died from myocardial infarction due to ischaemic heart disease and hypertension shortly after undergoing urology surgery. Critical failures in clinical communication prevented recognition of undiagnosed…
71y · Male·Organ failure in an elderly man receiving palliative medical care for renal fail…
Gheorghe Gruici, a 71-year-old life-sentenced prisoner, died of organ failure from chronic renal failure, infective endocarditis, and chest infection. Over 15 years in custody, he developed multiple comorbidities includi…
66y · Female·Pulmonary thromboembolism due to renal vein thrombus secondary to renal cell car…
Sylvia Crane, 66, died from pulmonary thromboembolism caused by tumour thrombus originating from renal cell carcinoma. She had a five-month delay in scheduling Category 1 surgery for nephrectomy due to systemic waitlist …
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