55y · Male·Pneumonia, bone marrow failure and metastatic carcinoma of unknown origin
…ion to Wodonga Hospital ED, he was admitted with ongoing abdominal pain. He deteriorated with respiratory failure from pneumonia, complicated by pancytopenia. Bone marrow biopsy revealed metastatic adenocarcinoma of unk…
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 undiagnose…
86y · Male·combined effects of acute myeloid leukaemia, acute renal failure and staphylococ…
…h, aged 86, died in custody at Royal Adelaide Hospital from combined acute myeloid leukaemia, acute renal failure, and staphylococcal pneumonia. He had a significant medical history including ischaemic heart disease, ca…
50y · Male·multi-organ failure due to pancreatitis and generalised varicella zoster virus i…
…les Andrew Tabb, a 50-year-old prisoner with non-Hodgkin's lymphoma (diagnosed 13 years prior, treated with bone marrow transplants), died of multi-organ failure from pancreatitis and disseminated varicella zoster virus …
39y · Male·Complications arising from widely disseminated primary pulmonary small cell carc…
…atment. The cancer presented atypically without classic signs until rapid decompensation with multi-organ failure on 21 February 2019. Autopsy revealed an extremely high-grade, aggressive tumour that had extensively inf…
41y · Male·Fulminant sepsis (Klebsiella pneumoniae) with multi-organ failure complicating s…
…itical post-discharge full blood count monitoring was not arranged effectively. The patient developed fatal bone marrow aplasia, sepsis and multi-organ failure. Key failures included: absence of written 6-MP prescribing …
58y · Male·Haemophagocytic lymphohistiocytosis, due to or as a consequence of T-cell lympho…
…osis of HLH was made on 16 November, but despite ICU management, he deteriorated rapidly into multi-organ failure and died 7 days later. A forensic medical review found that while earlier haematology review might have d…
4y · Male·acute lymphoblastic leukaemia
…He developed life-threatening complications including disseminated intravascular coagulation, respiratory failure requiring intubation, cerebral ischaemia, and intraocular haemorrhage. Despite appropriate management inc…
66y · Male·Bronchopneumonia and influenza A complicating cardiac and renal failure associat…
…ndary to non-Hodgkin's lymphoma died from bronchopneumonia and influenza A complicating cardiac and renal failure. He developed delirium, agitation and paranoia during his final admission, requiring an Inpatient Treatme…
69y · Female·Multiple organ failure due to secondary haemochromatosis (transfusion-associated…
Mrs Vicki Dow, 69, died from multiple organ failure secondary to iron overload (transfusion-associated haemochromatosis) from treatment of myelodysplastic sy…
78y · Male·Complications of blood loss from femoral fracture sustained in harness riding in…
…significantly worsens bleeding control in trauma; open femoral fractures cause uncontrollable bleeding from bone marrow that cannot be compressed by tourniquets or pressure dressings; permissive hypotension strategies mu…
72y · Male·Diffuse large B cell lymphoma
Douglas Stott, a 72-year-old prisoner with diffuse large B cell lymphoma, died of natural causes in hospital on 7 January 2021. He had been receiving telehealth oncology consultations while incarcerated but refused in-pe…
77y · Male·Complications of reaction to an iron infusion in a man with ischaemic heart dise…
A 77-year-old man with iron deficiency anaemia and underlying ischaemic heart disease died from anaphylaxis following iron polymaltose infusion. Critical clinical lessons: (1) IV iron should only be administered after or…
27y · Male·acute myeloid leukaemia
… GP who advised supportive care. Blood tests from 19 December were remarkably near-normal despite extensive bone marrow involvement found at autopsy. The coroner found clinical management adequate and appropriate, though…
66y · Male·multiple organ failure associated with the combined effects of complications of …
Daniel Lahengking, a 66-year-old Indonesian visiting family in Esperance, was diagnosed with rheumatoid arthritis by locum GP Dr H. and prescribed methotrexate 5-10mg daily, a grossly excessive dose (normal: 7.5-20mg wee…
17y · Male·Multi-organ failure with terminal fungal sepsis (Aspergillus) on a background of…
Ben Witham, a 17-year-old with acute lymphoblastic leukaemia, died from multi-organ failure with terminal fungal sepsis. The critical issue identified was a substantial delay in investigating acute…
69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…
Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest labo…
64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …
…ctive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart failure. Key clinical lessons include: (1) communication of medical information between facilities was inadequate…
31y · Female·organ failure due to anorexia nervosa
Chloe Tupper died of organ failure due to severe anorexia nervosa at age 31. She had suffered from this illness for 17 years since age 14, r…
61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed
… but remained unpublished; the cytology result was reported but never flagged as critical. These systemic failures in pathology communication and MDT processes resulted in inappropriate Hodgkin lymphoma treatment for an…
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