445 results
25y · Female·Airway obstruction complicating laryngeal dilation for the treatment of subglott…
Ms Sobb, a 25-year-old woman with spondylo-epi-metaphyseal dysplasia causing severe airway abnormalities and subglottic stenosis, died from airway obstruction following laryngeal dilation. She was admitted to ICU with as…
51y · Male·Pulmonary thromboemboli due to deep vein thrombosis on a background of a leg bur…
Stephen Kline, a 51-year-old Aboriginal man, died from pulmonary thromboembolism due to deep vein thrombosis following a leg burn wound sustained when NSW Police deployed a taser during a confrontation on 8 March 2016. H…
88y · Female·Sepsis complicated by multiple organ failure in a woman with comorbidities in th…
An 88-year-old woman died from sepsis with multiple organ failure following shoulder surgery. She developed an undiagnosed urinary tract infection after placement of an indwelling catheter. Critical failures included: in…
86y · Male·Complications post laparoscopic cholecystectomy
86-year-old man with acute gangrenous perforated cholecystitis underwent laparoscopic cholecystectomy on 2 October 2015, forty-two hours after admission. Severe bleeding from hepatic arterial branches required conversion…
47y · Female·hypoxic encephalopathy and aspiration pneumonia following aspiration of gastric …
Jodie Ann Pearson, aged 47, died from hypoxic encephalopathy and aspiration pneumonia following aspiration of gastric contents during a gastroscopy at Belmont Hospital on 15 February 2016. Critical pre-procedure informat…
72y · Male·hypovolemic shock due to haemoperitoneum following surgical repair of an abdomin…
A 72-year-old man died from hypovolemic shock due to intra-abdominal haemorrhage following Spigelian hernia repair. Post-operatively he presented with hypotension, bradycardia and sweating. ECG changes were misinterprete…
58y · Female·lymphangitic carcinomatosis leading to hypoxaemic respiratory failure and cardia…
June Nutter, a 58-year-old woman presenting with weight loss, anorexia, and unexplained shortness of breath, underwent gastroscopy and colonoscopy at a private hospital to investigate suspected gastric pathology. She had…
34y · Female·Complications of fall with fractured ankle and subsequent deep venous thrombosis…
Anna Bowditch, aged 34, died from complications of deep venous thrombosis (DVT) with pulmonary embolism and paradoxical stroke following elective fracture repair surgery. She had multiple known DVT risk factors: immobili…
46y · Male·COMPLICATIONS OF RUPTURED ANTERIOR COMMUNICATING CEREBRAL ARTERY ANEURYSM (OPERA…
Jason Causon, a 46-year-old man in custody, collapsed while exercising due to a ruptured anterior communicating cerebral artery aneurysm. He received prompt initial resuscitation by correctional and health staff, was rap…
50y · Male·Multi-organ failure caused by low flow ischaemia of coeliac artery and superior …
Adrian Van Die, a 50-year-old with severe ischaemic cardiomyopathy, underwent coronary artery bypass grafting with intra-aortic balloon pump (IABP) support. The first IABP ruptured intraoperatively and was replaced. The …
12y · Female·Cardio-respiratory failure due to aspiration pneumonia
Angelique Burton-Ho, age 12, with VACTERL syndrome and difficult airway, presented to Bowral Hospital ED on 9 August 2015 with respiratory symptoms. She was inadequately triaged initially, then readmitted that evening wi…
12y · Male·Cardiac haemorrhage due to or as a consequence of congenital aortic stenosis (su…
Joshua Statis, a 12-year-old with complex congenital aortic stenosis, died 18 days after a redo Konno procedure and aortic valve replacement when a CardioCel patch to the right ventricular outflow tract (RVOT) ruptured, …
58y · Male·metastatic carcinoma of the pancreas
David Dufty, aged 58, died from metastatic pancreatic cancer while detained under a Mental Health Act treatment order in the ICU of Royal Hobart Hospital. He was admitted with psychosis in December 2016. On 5 January 201…
78y · Male·Complications of blood loss from femoral fracture sustained in harness riding in…
A 78-year-old man with ischaemic heart disease on warfarin sustained a compound femoral fracture with massive bleeding after a harness racing accident in a rural location. Despite exemplary prehospital care and timely he…
56y · Male·Hypoxia and cardiac arrest with contributing conditions of Ischaemic Heart Disea…
A 56-year-old man with diabetes, ischaemic heart disease, morbid obesity, and an implanted defibrillator underwent minor toe debridement surgery. The anaesthetist failed to conduct an adequate pre-operative assessment, u…
67y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …
David Fensom, 67, underwent elective fundoplication for hiatus hernia and reflux on 21 September 2010. He developed severe right-sided abdominal pain post-operatively. A laparoscopy on 8 October misinterpreted findings a…
0y · Female·Intracranial and intrapulmonary haemorrhage due to traumatic head injury from fa…
Baby M died shortly after birth on 11 February 2016 at Gladstone Base Hospital from intracranial and intrapulmonary haemorrhage due to traumatic head injury from a fall, complicated by Group B Streptococcal sepsis. A nur…
39y · Male·Hypoxic/Ischaemic Encephalopathy due to Cerebral Arterial Gas Embolism
Phillip Ibrahim, a 39-year-old man recovering well from community-acquired pneumonia in ICU, suffered a fatal cerebral air embolism on 28 October 2014. A CVAD removal order was given at midday but the device remained in …
24y · Male·Hypoxic-ischaemic encephalopathy, due to or as a consequence of cardiac arrest, …
Hamid Khazaei, an Iranian asylum seeker aged 24, died on 5 September 2014 after contracting a leg infection (Chromobacterium violaceum) on Manus Island while in immigration detention. His death was preventable and result…
73y · Male·Consequences of myocardial infarction with coronary artery atherosclerotic disea…
Leonard Bartholomeusz, aged 73, died of myocardial rupture on 6 May 2013, six days after hip fracture surgery. He suffered a fall on 30 April 2013 following which ECG testing revealed cardiac abnormality. A first ECG at …
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