445 results
60y · Female·Peritonitis due to anastomotic leak following subtotal colectomy for treatment o…
60-year-old woman died from septic shock due to anastomotic leak following subtotal colectomy for synchronous bowel cancers. Early postoperative bronchospasm complicated clinical assessment, leading focus on respiratory …
0y · Female·Pulmonary hypoplasia in the setting of ascending maternal genital tract infectio…
Hannah McNeil, a term neonate, died from pulmonary hypoplasia secondary to ascending maternal genital tract infection. She was born via emergency caesarean section after induction of labour for brow presentation. Despite…
57y · Female·Intra-abdominal Haemorrhage following Appendectomy, with contributing factor of …
A 57-year-old woman with COAD, hypertension, and unrecognized severe coronary atherosclerosis presented with appendicitis. Surgery was performed by an unsupervised surgeon operating on friable tissues with limited visibi…
57y · Male·Multiple Organ Failure and Intra-Abdominal Haemorrhage following Cholecystectomy
A 57-year-old man with multiple comorbidities (obesity, diabetes, hypertension, COAD, sleep apnoea) underwent elective laparoscopic cholecystectomy at a regional hospital. The procedure was converted to open due to dense…
38y · Male·Heart failure in a man with dilated cardiomyopathy and focal severe coronary art…
Anthony Axtell, a 38-year-old man with severe dilated cardiomyopathy from amphetamine use, died of heart failure while in prison custody. Initially treated successfully in 2002 with recovery to normal cardiac function by…
75y · Female·Abdominal infection following surgery (repair of recurrent umbilical hernia) - s…
Wilma Ray Jones, 75, died of abdominal infection and sepsis following uncomplicated umbilical hernia repair. Post-mortem revealed ischaemic bowel with infarction, likely caused by superior mesenteric artery occlusion tri…
51y · Male·Multiorgan failure in a man with corrected congenital coarctation of the aorta a…
Sean Raymond Adams, 51-year-old male with complex cardiac history including corrected coarctation of aorta, valvular disease, and biventricular heart failure, presented to Alfred Hospital ED with chest pain and dyspnoea.…
77y · Female·Complications following a recent fracture and surgical repair of the right hip i…
A 77-year-old woman with complex comorbidities (atrial fibrillation, aortic stenosis, chronic renal impairment, emphysema) on Warfarin sustained a femur fracture and underwent ORIF on day 3 of admission (19 Nov 2009). Ke…
86y · Male·Acute Myocardial Ischaemia in an Elderly Man with Valvular and Ischaemic Heart D…
Henry Edwin Kerr, 86, died of acute myocardial ischaemia following left inguinal hernia surgery at Esperance District Hospital. He had significant cardiac history including valvular disease, ischaemic heart disease, and …
74y · Female·Cardio-renal failure due to gangrene of calculous gallbladder, with significant …
An elderly woman with a documented penicillin allergy, wearing a MedicAlert bracelet, presented to emergency with respiratory distress and chest pain. She was administered intravenous Ampicillin without allergy verificat…
26y · Male·Multiple injuries from collision between semi-trailer and train at level crossin…
On 5 June 2007, a semi-trailer collided with a V/Line passenger train at the Kerang level crossing, killing 11 passengers. The driver had crossed this crossing hundreds of times without seeing a train, was familiar with …
50y · Male·Multiple injuries sustained in collision between semi-trailer and train
A comprehensive coronial investigation into 26 deaths from 12 level crossing collisions in Victoria (2002-2009), with particular focus on the Kerang incident (5 June 2007) in which 11 train passengers died when a semi-tr…
68y · Female·Anaphylaxis in a woman with atherosclerotic cardiovascular disease and emphysema
A 68-year-old woman with severe COPD and undiagnosed atherosclerotic heart disease underwent cataract surgery at Northam Hospital. Post-operatively, she was prescribed Diamox (acetazolamide), a sulphonamide medication. D…
37y · Female·Hypoxic brain injury complicating cardiorespiratory arrest during manual removal…
A 37-year-old primigravida with gestational diabetes was admitted for labour induction at 37 weeks. Following vaginal delivery and delayed placental separation, manual removal of placenta was performed under spinal anaes…
0y · Female·Cerebral hypoxia due to placental abruption
Sophie Sparreboom died from cerebral hypoxia secondary to placental abruption following emergency caesarean section. Gestational diabetes indicated planned induction at term. At 2050 hours, antepartum haemorrhage and pat…
27y · Female·opiate toxicity (fentanyl)
Hayley Fisher, a 27-year-old midwife at King Edward Memorial Hospital, died from accidental opiate toxicity after injecting a fatal quantity of fentanyl she obtained from a patient-controlled analgesia device. She had a …
39y · Male·propofol toxicity
Craig Doherty, a 39-year-old clinical theatre nurse at Royal Perth Hospital, died from propofol toxicity in June 2010. He had unrestricted access to propofol as an anaesthetic agent and misappropriated it for recreationa…
92y · Female·acute myocardial infarction
Linda Edith Bugg, aged 92, died of acute myocardial infarction at Royal Adelaide Hospital on 24 October 2009. She was admitted from Howard House with nausea, vomiting, and hypotension; tests indicated acute heart attack.…
64y · Male·hypoxic-ischaemic encephalopathy complicating cardiac arrest due to retroperiton…
A 64-year-old man died from hypovolaemic cardiac arrest caused by retroperitoneal bleeding from a pelvic fracture. The bleeding occurred six days post-injury while on high-dose enoxaparin (100mg twice daily) initiated un…
71y · Male·Multi organ failure due to post-operative bleeding following endoluminal thoraci…
William Colhoun, 71, underwent complex endovascular repair of thoracic-abdominal aortic aneurysm at St Vincent's Private Hospital on 1 December 2008. He developed post-operative instability with hypotension, metabolic ac…
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