78y · Female·multi-organ failure due to haemorrhage into the abdomen, pelvis and retroperiton…
…ndary to intra-abdominal and retroperitoneal haemorrhage following extensive anterior and posterior lumbar spinal fusion surgery. The patient had multiple comorbidities, previous spinal surgery with persistent pain, oste…
49y · Male·complications of a cervical spine injury
…tenosis). He lay on the floor for over 9 hours before discovery. Although anterior cervical discectomy and fusion surgery was performed successfully, he developed pneumonia post-operatively and died on 15 October 2017 fr…
54y · Male·Complications of cervical spinal stenosis treated with cervical laminectomy and …
…lity, blindness, and perinatal hypoxic-ischemic brain injury, underwent indicated cervical laminectomy and fusion for cervical stenosis. Post-operatively, he self-removed a drainage tube, then developed a wound infection…
65y · Male·Traumatic high cervical spine injury in the setting of frontal head impact in a …
…e sergeant's leg and fell forward striking his head and face. His pre-existing condition causing vertebral fusion made him highly vulnerable to severe injury from minimal force. The fall caused C2 and C5/6 vertebral frac…
86y · Female·Pulmonary thromboembolism in the setting of deep leg vein thrombosis, secondary …
Barbara Deal, 86, died from pulmonary embolism secondary to deep vein thrombosis 17 days after lumbar spinal fusion surgery. Critical failures included: no repeat VTE risk assessments despite policy requirements; in…
89y · Male·fractured cervical spine (C5 inferior articular process fracture) due to unwitne…
…spine fracture. Initial CT imaging missed the C5 inferior articular process fracture, reporting only a paraspinal haematoma. Conservative management with mobilisation by an occupational therapist caused ligament disrupti…
33y · Female·Immersion (drowning) by suicide
Elizabeth Ann Studd, a 33-year-old woman with longstanding borderline personality disorder, died by drowning in the Swan River on 28 August 1999. She had a severely traumatic childhood characterised by emotional neglect,…
11y · Female·pneumonia complicating cytomegalovirus embryopathy
…eiving exceptional care including medical management of multiple complications (epilepsy, aspiration risk, spinal deformity, recurrent infections). By 2001, her condition deteriorated significantly with progressive respi…
17y · Male·Hypoxic ischaemic encephalopathy due to hanging
…after discharge from psychiatric inpatient care. He had complex medical needs including chronic back pain, spinal fusion, post-viral fatigue, depression, anxiety, and gender dysphoria. Critical clinical lessons include: …
76y · Male·Bronchopneumonia in a man with ischaemic heart disease and treated spinal crush …
John Hayle, a 76-year-old with Alzheimer's dementia, ischaemic heart disease, and spinal fractures sustained a T11/12 flexion-distraction fracture on 9 June 2017. Over three weeks, he developed p…
54y · Male·Neck injuries sustained in a fall - fracture of the fifth cervical vertebra (car…
…l palsy, intellectual disability, Lennox-Gastaut syndrome with frequent seizures, and prior cervical spine fusion (2001) that rendered his neck rigid and vulnerable to catastrophic injury from minor trauma. Between mid-F…
74y · Male·Pulmonary thromboembolism secondary to deep vein thrombosis in the setting of re…
…74-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis following a cervical spinal fracture. He presented to rural ED with mental health concerns, was restrained by security guards after br…
60y · Female·Penetrating injury of the descending thoracic aorta complicating spinal stabiliz…
A 60-year-old woman died from a penetrating injury to the descending thoracic aorta sustained during spinal stabilisation surgery for a T12 burst fracture. During pedicle cannulation, the surgical awl fractured the…
12y · Female·Raised intracranial pressure due to acute-on-chronic hydrocephalus in the contex…
Samantha Rose Spence, 12 years old, died two days after spinal fusion surgery for severe scoliosis. She had a pre-existing, asymptomatic Chiari type 1 malformation detec…
75y · Male·left retroperitoneal haemorrhage associated with lumbar spine surgery
A 75-year-old man with complex comorbidities including Parkinson's disease and cognitive impairment underwent two-stage lumbar spine surgery for degenerative disc disease with stenosis. Post-operatively, he developed a r…
11y · Female·Pneumonia complicating cerebral palsy secondary to KCNQ2 developmental and epile…
HD was an 11-year-old girl with severe cerebral palsy, epilepsy, and multiple complex medical conditions including central respiratory depression and recurrent chest infections. She died from pneumonia at home in August …
33y · Female·Hypoxic ischaemic encephalopathy complicating mixed drug toxicity
…ence, died from hypoxic ischaemic encephalopathy following mixed drug toxicity. She underwent a ketamine infusion with opioid rotation from oxycodone to methadone at Victorian Rehabilitation Centre (16-23 May 2017). Post…
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