445 results
35y · Male·intraperitoneal haemorrhage from an anastomotic leak from a transplanted renal a…
Luke Wood, a 35-year-old kidney transplant recipient, died 11 days post-transplant from intraperitoneal haemorrhage due to anastomotic leak from the transplanted renal artery. While post-operative inpatient care and init…
0y · Male·Perinatal hypoxic ischaemic encephalopathy with severe diffuse cortical necrosis…
George Darcy Key, an 8-day-old neonate, died from perinatal hypoxic ischaemic encephalopathy following labour complicated by excessive syntocinon-induced contractions and delayed obstetric intervention. The infant was de…
10y · Male·Hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…
A 10-year-old boy with severe obstructive sleep apnoea and morbid obesity died from hypoxic brain injury following cardiorespiratory arrest. Despite repeated medical interventions and explicit warnings that his condition…
77y · Female·Venlafaxine toxicity in a woman with severe renal impairment and depression
77-year-old woman admitted to psychiatric ward with severe depression and catatonic features. Despite documented severe renal impairment and dehydration on admission, no medical review occurred over the weekend prior to …
68y · Female·Haemorrhage secondary to right subclavian artery lacerations sustained during ce…
A 68-year-old woman died from massive blood loss following inadvertent puncture of the right subclavian artery during central venous line insertion. The anaesthetist used anatomical landmarks without ultrasound after an …
62y · Female·Multi-organ failure due to lacerated abdominal aorta complicating laparoscopic b…
A 62-year-old woman died from multi-organ failure caused by a lacerated abdominal aorta sustained during elective laparoscopic gastric band surgery in 2006. The aorta was cut by a Visiport trocar blade at the start of th…
0y · Female·Sepsis
Baby Lily Irwin died of sepsis caused by ascending bacterial infection (Staphylococcus aureus) that developed after spontaneous rupture of maternal membranes 48 hours prior to delivery. The infection caused chorioamnioni…
0y · Female·Intra-uterine hypoxia
Baby Paula O'Shea was born at Sandringham Hospital at term following spontaneous labour. Labour was augmented with IV Syntocinon after ARM. Cardiotocography (CTG) monitoring was difficult to interpret due to poor detecti…
52y · Female·laceration of the superior vena cava and right atrium during defibrillator lead …
A 52-year-old woman with a history of syncope and mitral valve prolapse, who had an implanted defibrillator, underwent a percutaneous laser lead extraction procedure at Westmead Hospital to remove and replace defective l…
82y · Male·hypoxic-ischaemic encephalopathy due to cardiac arrest as a result of fractured …
An 82-year-old man died from hypoxic-ischaemic encephalopathy following perioperative cardiac arrest during ankle fracture surgery. The anesthetist failed to recognise clinical deterioration, did not intubate despite sig…
61y · Female·Peritonitis due to anastomotic leak at gastrectomy site; pathological obesity as…
A 61-year-old woman with pathological obesity died from peritonitis secondary to anastomotic leak following laparoscopic sleeve gastrectomy. The procedure itself was appropriate for her failed previous lap band surgeries…
0y · Unknown·focal ventricular myocarditis and myonecrosis resulting from migration of a Peri…
A 10-month-old boy died from myocarditis and myonecrosis caused by migration of a PICC line into his right ventricle. The line was inserted appropriately under general anaesthetic for IV antibiotics treating periorbital …
45y · Male·Sudden death of unascertained cause, occurring eight days after laparoscopic cho…
A 45-year-old man died unexpectedly 8 days after an uncomplicated laparoscopic cholecystectomy. Post-mortem examination found approximately 1 litre of blood in the peritoneal cavity. Pathologists could not determine when…
34y · Female·Combined drug toxicity (propofol, sevoflurane and others)
A 34-year-old anaesthetist at Royal Melbourne Hospital died from combined drug toxicity involving propofol and sevoflurane—anaesthetic agents she accessed from unlocked theatre trolleys and administered to herself at hom…
31y · Female·Ruptured splenic artery aneurysm with extensive retroperitoneal and intraperiton…
Michelle Johnson, a 31-year-old pregnant woman at 32 weeks gestation, presented to the Royal Women's Hospital with sudden-onset severe left-sided abdominal pain and hypotension on 21 March 2010. She was assessed by regis…
29y · Male·Bronchopneumonia complicating neck injuries sustained in a fall, with Coffin-Low…
A 29-year-old man with Coffin-Lowry Syndrome suffered a severe cervical spinal cord injury from a fall at a respite facility. Disability workers found him on the floor but initially interpreted his presentation as non-co…
79y · Female·aspiration pneumonia caused by aspiration of emesis secondary to small bowel obs…
Mrs Little, 79, died from aspiration pneumonia caused by small bowel obstruction post-hysterectomy surgery. The obstruction resulted from both pre-existing adhesions and a post-operative haematoma at the surgical site. C…
56y · Female·hypoxic ischaemic encephalopathy due to inadvertent oesophageal intubation and f…
Sukanya Thurairajah, 55-year-old with multiple comorbidities including obesity, diabetes, coronary disease, and metastatic breast cancer, underwent haemodialysis at Canberra Hospital on 29 July 2011. She had an adverse r…
0y · Male·complications of intrauterine hypoxia
Baby Jacob Hill died from intrauterine hypoxia following an obstructed labour managed at Sunshine Hospital. A 39-week primiparous labour was complicated by deep transverse arrest. After initial assessment suggesting caes…
Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…
Two obese patients died from hypoxic-ischaemic encephalopathy following cardio-respiratory deterioration post-operatively at a private hospital without overnight medical cover. John Ryan (54) deteriorated within hours of…
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