236 results for “orthopaedic surgery”
67y · Male·ischaemic heart disease
A 67-year-old man with ischaemic heart disease and paroxysmal atrial fibrillation underwent arthrotomy for septic arthritis of the knee. He developed post-operative delirium attributed to anaesthesia, analgesics (tramado…
85y · Female·Sepsis relating to an infected right shoulder wound (including MRSA)
Ellen Plymin, aged 85, sustained a fractured humerus in a fall and underwent surgical fixation at Western Hospital on 10 May 2007. She returned to Westgate Aged Care Facility post-operatively on 14 May. By 28 May, wound …
85y · Female·neck injury (cervical spine fracture) as a consequence of a fall
Mrs Florence Thomas, 85, died from cervical spine fractures sustained when she fell from a toilet chair at her nursing home. She had multiple documented falls and explicit care plan instructions never to be left alone on…
1y · Female·unrecognised oesophageal intubation
A 19-month-old girl died from unrecognised oesophageal intubation during anaesthesia for finger laceration repair. The anaesthetic team failed to recognise multiple clinical indicators of tube misplacement: absence of pe…
74y · Female·Fractures of the legs, with terminal palliative care, in an elderly lady with mu…
Ms Papanastasiou, a 74-year-old aged care resident confined to a wheelchair, died from bilateral femoral fractures sustained when she fell from her wheelchair during sudden bus braking. The wheelchair was secured using o…
47y · Female·Mixed drug toxicity (venlafaxine, duloxetine, mirtazapine, oxycodone, tapentadol…
Kim Bartolo, a 47-year-old woman with depression, anxiety, alcohol use disorder and chronic conditions, died from mixed drug toxicity involving multiple prescription medications. She was admitted to Brunswick Private Hos…
92y · Male·Consequences of accidental fall at RACF: post-operative delirium, left femoral i…
A 92-year-old man resident in an aged care facility sustained an unwitnessed fall resulting in left hip fracture, requiring surgical fixation. He developed post-operative delirium and died 8 days later. The coroner ident…
42y · Male·Cardiac arrest following hypoxic ischaemic encephalopathy, likely due to E.coli …
Jarrod Wright, a 42-year-old man admitted with cellulitis, developed sepsis-related acute respiratory distress syndrome (ARDS) requiring ICU care with non-invasive ventilation. Critical failures occurred in managing his …
54y · Male·aspiration pneumonia caused by multiple drug toxicity
Paul Lau, aged 54, died from aspiration pneumonia caused by opioid toxicity following ACL reconstruction surgery. The death resulted from a prescribing error where anaesthetist Dr K. inadvertently prescribed a 100mcg/h…
52y · Male·Stab injuries to the chest
Mark Edwards, a 52-year-old man, died by suicide via stab injuries to the chest on 11 December 2020. He had suffered a workplace injury in 2007 resulting in amputation of his right leg in 2017, chronic pain, multiple sur…
87y · Female·pneumonia following complications from a fractured left wrist sustained in a fal…
Mrs Webberley, 87, resident of a residential aged care facility (RACF), sustained an unwitnessed fall on 1 November 2021 resulting in a left wrist fracture (Colles' fracture). She was initially assessed at the RACF but n…
84y · Male·respiratory failure due to hospital-acquired pneumonia
Ronald Geoffrey Weeks, aged 84, died of respiratory failure due to hospital-acquired pneumonia following a hip fracture sustained in a fall at James Nash House psychiatric facility. He was serving an 8-year sentence for …
56y · Male·Complications of atraumatic bilateral femoral fractures (repaired) during a seiz…
Mark O'Brien, a 56-year-old man with Down syndrome and dementia, sustained multiple seizure-related bilateral femoral fractures. A subtle posterior cortical fracture to his left femur, sustained during a seizure on 15 Ju…
65y · Male·Cardiac arrhythmia, probably Torsades de Pointes, due to the combined effects of…
…s) precipitated by methadone prescribed with inadequate oversight. Mr Phillips had chronic pain from knee surgery, severe sleep apnoea, and was opioid-dependent. Dr H., an addiction specialist, prescribed Physeptone (me…
75y · Female·multiple injuries due to or as a consequence of motor vehicle collision
Ruth Capps, 75, died in a motor vehicle collision after drifting into oncoming traffic. She had multiple medical conditions including diabetes, sleep apnoea, chronic back pain, osteoarthritis, and recurrent falls. Despit…
70y · Male·hypovolaemic shock due to the consequences of fractured femur
Thomas Fulcher, a 70-year-old man with intellectual disability and osteoporosis in a group home, fell on 19 January 2018 and sustained a spiral femur fracture with internal bleeding. Care workers failed to seek medical a…
28y · Male·hypovolemia secondary to haemorrhage from operative exploration of multiple stab…
…tion of multiple stab wounds to the thigh. The death was preventable. Critical failures included: delayed surgery from Friday to Saturday (out-of-hours), leading to increased swelling and operational difficulty; underes…
36y · Male·Combined drug toxicity (pregabalin, morphine, amitriptyline)
A 36-year-old motor mechanic with chronic pain from a 2014 knee injury died from combined drug toxicity (pregabalin, morphine, amitriptyline). His general practitioner, Dr S., prescribed excessive amounts of multiple med…
24y · Male·Peritonitis secondary to a perforation of the small bowel
…one-to-one care. The clinical lesson is that suspected bowel injury requires either immediate exploratory surgery or strict close observation with senior review within hours. Drug intoxication should not delay surgical …
74y · Male·Pulmonary thromboembolism secondary to deep vein thrombosis in the setting of re…
A 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 …
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