445 results
28y · Male·Brain death resulting from exsanguination and hypovolaemic arrest due to severed…
Joshua David Smart, a 28-year-old scaffolder, died from brain death resulting from catastrophic exsanguination and hypovolaemic arrest. At approximately 4:45 am on 20 March 2014, whilst attempting to stop dogs fighting o…
44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)
Jimmy James, a 44-year-old man, died from pneumonia with multiple left-sided rib fractures secondary to a physical assault. He presented to Westmead Hospital ED with clinical signs of septic shock (tachypnoea, hypoxia, h…
2y · Male·Tramadol toxicity in the setting of adenotonsillectomy in a child with Pierre Ro…
Dane Hortle, a 2-year-old with Pierre Robin Sequence and obstructive sleep apnoea, died from tramadol toxicity following adenotonsillectomy. He was discharged with a prescription for tramadol 25mg, which was dispensed as…
8y · Female·Anoxia due to fresh water drowning
Child A, aged 8 years, drowned at Lake Dyer recreational dam after receiving a blow to the face, likely from a boat at a busy boat ramp. Despite being a confident swimmer, the impact caused panic and fright reaction prev…
36y · Female·Haemorrhage complicating elective caesarean section (placenta praevia accreta)
Ms. Thi Lu, aged 36, died from massive hemorrhage following caesarean section for placenta praevia with underlying placenta accreta. Although imaging could not definitively exclude accreta preoperatively, high-risk prepa…
77y · Male·Cerebral infarction (stroke) complicating elective hernia repair
A 77-year-old man with atrial fibrillation on warfarin underwent elective hernia repair. Warfarin was appropriately ceased five days pre-operatively. Post-operatively, warfarin was recommenced on day 1 post-op at 5pm. He…
55y · Male·ruptured dissection of the thoracic aorta
Tien Chung Nguyen, a 55-year-old male prisoner, died from rupture of a thoracic aortic dissection during emergency surgery at Royal Perth Hospital. He presented with chest pain and dyspnoea at Wooroloo Prison on 26 Novem…
0y · Female·Congenital Streptococcus agalactiae (Group B) pneumonia in the setting of compli…
Baby Mabel Windmill was born in a moribund state following emergency caesarean section after complicated labour and died from congenital Group B streptococcal pneumonia. The inquest identified several suboptimal clinical…
72y · Male·Multiple organ failure due to sepsis caused by abdominal adhesions from previous…
Michael Hamilton, 72, presented with acute abdominal pain post-bladder surgery while anticoagulated with warfarin. Initial assessment suspected duodenal perforation based on CT findings; laparotomy was performed but foun…
86y · Male·Septic shock secondary to urosepsis
Robert Avery, 86, was admitted to Valley Private Hospital for colonoscopy to investigate constipation. After the procedure was cancelled due to respiratory concerns, he was managed with fluid restriction, bowel preparati…
62y · Female·acute subarachnoid haemorrhage following perforation of the anterior communicati…
Ann Margaret Sansom, a 62-year-old woman with Type 2 diabetes and cirrhosis, died from subarachnoid haemorrhage following perforation of the anterior communicating artery during an endovascular coiling procedure for a 3m…
5y · Female·Cerebral hypoxic and ischaemic injury in a setting of clinical birth asphyxia
Chloe Kellett was born at 39 weeks gestation after induction of labour for rupture of membranes and group B streptococcus positivity. She was delivered by forceps in theatre for a non-reassuring cardiotocogram (CTG) trac…
32y · Male·Pulmonary embolism originating from deep vein thrombosis in right calf
A 32-year-old man died from pulmonary embolism six days after emergency appendectomy for perforated appendicitis. VTE prophylaxis was appropriately prescribed. However, the clinical team failed to investigate persistent …
50y · Male·Mixed drug toxicity (propofol, codeine, diazepam)
Mark Wilson, a 50-year-old registered nurse at The Avenue Private Hospital, died from mixed drug toxicity involving propofol, codeine, and diazepam. He had access to propofol through his workplace and was found dead at h…
39y · Female·Hypoxic brain injury secondary to multiple hypovolaemic cardiac arrests from cat…
Linda Parker, aged 39, died from hypoxic brain injury following catastrophic postpartum haemorrhage from placenta increta during caesarean delivery. Critical lessons: (1) Placenta increta risk was not detected prenatally…
48y · Male·myocardial infarction due to ischaemic heart disease due to hypertension
A 48-year-old man died from myocardial infarction due to ischaemic heart disease and hypertension shortly after undergoing urology surgery. Critical failures in clinical communication prevented recognition of undiagnosed…
63y · Male·Right cerebral infarction caused by infusion of medication via central venous li…
A 63-year-old man with COPD, liver cirrhosis and alcohol dependence underwent emergency hemicolectomy for caecal volvulus. Post-operatively he developed respiratory depression, hypernatremia and alcohol withdrawal requir…
48y · Male·undetermined
A 48-year-old man with schizoaffective disorder, poorly controlled diabetes, sleep apnoea, obesity and cardiomegaly died unexpectedly at a rural hospital following acute psychotic agitation. He had absconded from a menta…
50y · Male·myocardial infarction caused by coronary atherosclerosis
Desmond Jambajimba Tilmouth, a 50-year-old Aboriginal man, died of myocardial infarction from severe coronary atherosclerosis complicated by end-stage renal disease and an incarcerated strangulated umbilical hernia. He d…
Male·Hypoxic-ischaemic encephalopathy due to meconium aspiration syndrome
A full-term baby born at 39 weeks died from hypoxic-ischaemic encephalopathy due to meconium aspiration. Critical failures in fetal monitoring were identified: the admission CTG was abnormal but not recognised as such by…
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