17y · Male·stroke (left middle cerebral artery infarction) following motorbike collision du…
…tical clinical lesson involves a missed diagnosis of left internal carotid artery dissection on initial CT scans (27 May 2021). Although appropriate angiographic imaging was ordered by the emergency physician, the radio…
64y · Male·Complications of Creutzfeldt-Jakob Disease following a fall
…oner found that while BHS head injury guidelines did not reflect current standard practice recommending CT scans for anticoagulated patients with head strikes, earlier imaging would not have altered the outcome as his d…
9y · Male·Head injury (epidural haematoma with cerebral coning following craniotomy)
Dwayne Michael Jones, aged 9, had Trisomy 10, a rare congenital chromosomal disorder causing severe developmental delay and neurological abnormalities. On 11 April 2000, he fell from a computer desk and struck his head. …
44y · Male·pneumonia and possible large left cerebrovascular accident (stroke) in a man wit…
… residential care unit bed on 15 June 2008 and could not be revived. The forensic pathologist, based on CT scans and medical records without autopsy, determined death resulted from pneumonia and a possible large left ce…
68y · Male·surgical complications following laparoscopic cholecystectomy for cholecystitis,…
…gan failure followed. Key lessons: blood loss is the default diagnosis in acute post-operative shock; FAST scans have significant limitations and are unreliable in post-operative settings; drain settings must be verifie…
55y · Male·Haemorrhagic brain stem infarction due to hypertensive heart disease
…e in the bathroom, one near his bed). Initial imaging showed no acute pathology, but subsequent CT and MRI scans revealed subarachnoid haemorrhage and extensive brain stem infarction. He was transferred to Brisbane wher…
71y · Female·Haemothorax and haemopericardium secondary to ruptured dissecting aneurysm of th…
A 71-year-old woman with hypertension and prior myocardial infarction presented to emergency with sudden chest pain, jaw pain, and syncope. Aortic dissection was appropriately suspected and a contrast CT-aortagram was pe…
70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia
70-year-old Sean Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner identified multiple significant failing…
61y · Male·Coronary atherosclerosis
…cardiovascular risk factors including Type 2 diabetes, heavy smoking history, and intravenous drug use. CT scans in 2013 and 2015 revealed severe abdominal aortic calcification, later noted as 'age-advanced atherosclero…
54y · Female·Pneumonia - chest sepsis
…nd progressive weight loss and frailty. Despite extensive investigations including ultrasound, CT, and PET scans during her May-June 2023 hospitalisation, the underlying cause of her illness was not identified. She was …
15y · Male·Cerebral ischaemia in a young man with a blocked ventricular peritoneal shunt an…
Vaughn Richard Rasmussen, a 15-year-old boy with congenital abnormalities and a ventricular-peritoneal (VP) shunt, died from cerebral ischaemia caused by acute blockage of his VP shunt on 17 November 2009. Between 12-16 …
71y · Male·metastatic papillary renal cell carcinoma
Robert Bell-Williams, aged 71, died from metastatic papillary renal cell carcinoma while in lawful custody at Long Bay Hospital on 1 February 2024. Imprisoned since 2012, he was diagnosed with renal cell carcinoma in 202…
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…
51y · Female·Aspiration pneumonia in a woman with Down syndrome and Alzheimer's dementia
Angela Thompson, a 51-year-old woman with Down syndrome and early-onset Alzheimer's dementia, died from aspiration pneumonia following a shoulder fracture. She was in DHS supported residential care when she suffered freq…
53y · Female·sepsis and multiple organ failure attributable to infarction/necrosis of small b…
A 53-year-old woman with Type II diabetes, obesity, and Korsakoff dementia presented with acute severe abdominal pain from superior mesenteric artery (SMA) thrombosis at 3:00 AM on 19 August. Despite elevated lactate, me…
72y · Male·Cranial fracture and intracranial haemorrhage from self-inflicted fall
Frank Sette, a 72-year-old man with longstanding schizophrenia, died from a cranial fracture and intracranial haemorrhage sustained when he deliberately threw himself backwards onto the floor of a psychiatric ward. He wa…
45y · Male·intracerebral haemorrhage caused by rupture of arterial aneurysm
A 45-year-old man with an intracerebral haemorrhage from a ruptured aneurysm presented to an emergency department and general practice on multiple occasions in October 2005 with headache, vomiting, dizziness, and neck st…
43y · Female·Multisystem organ failure and hypoxic/ischaemic encephalopathy following anaphyl…
Peta Hickey, a 43-year-old company executive with no cardiac history, died from anaphylaxis to CT coronary angiogram contrast after her employer commissioned an inappropriate screening program. The referral lacked clinic…
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 R.'s failure to diagnose stroke on 7 September and arrange u…
38y · Male·metastatic lung carcinoma
…or appetite, and a persistent cough. Despite multiple medical consultations and investigations (X-rays, CT scans), imaging focused on musculoskeletal pathology and missed the underlying malignancy. When sent to Bendigo …
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