77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…
77-year-old male died from complications of haemothorax and hypotension following drainage of pleural effusion post-coronary bypass surgery, in the setting of pre-existing renal impairment and diabetes. Duri…
58y · Male·adenocarcinoma of the right lung
…esented in November 2007 with respiratory symptoms initially misdiagnosed as infection; chest imaging and pleural fluid analysis eventually confirmed lung cancer. He received appropriate multidisciplinary care including…
33y · Male·Haemoperitoneum secondary to lacerated spleen as a result of peritoneal ascitic …
…gh C) and poor prognosis died from haemoperitoneum following splenic laceration during a diagnostic ascitic tap procedure. Two junior doctors (HMOs/Basic Physician Trainees) performed the procedure unsupervised without …
53y · Male·Complications of metastatic rectal cancer
Thomas Millar, a 53-year-old man in custody, died from complications of metastatic rectal cancer with liver failure. He had been diagnosed with advanced cancer in 2015 with a poor prognosis and underwent chemotherapy whi…
65y · Male·Metastatic disease with gastrointestinal primary (adenocarcinoma)
Ronald Nieuwenhuis, a 65-year-old man with intellectual disability residing in supported accommodation, presented to hospital in January 2025 with abdominal pain and was found to have metastatic adenocarcinoma of gastroi…
73y · Male·metastatic carcinoma of the lung with palliation
Norman Hazelgrove, a 73-year-old prisoner, died from metastatic lung carcinoma in September 2017. Early in his imprisonment (2013), a chest X-ray showed COPD but this diagnosis was not formally documented or managed desp…
60y · Male·cardiorespiratory failure due to malignant pleural effusion due to metastatic ma…
…y metastasised to regional lymph nodes. The melanoma subsequently spread to the pleura and lungs, causing pleural effusion. The patient died in November 2008 from cardiorespiratory failure. Key clinical lessons: plantar…
53y · Male·disseminated malignant melanoma
A 53-year-old man died of disseminated malignant melanoma while incarcerated at Yatala Labour Prison. Initial excision of a large arm mole in November 2019 revealed Stage III melanoma. A January 2020 multi-disciplinary t…
68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…
Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mi…
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