918 results
acute myeloid leukaemia
Four patients with acute myeloid leukaemia died after receiving chemotherapy consolidation therapy that was administered once daily instead of the intended twice daily schedule due to a protocol error. The error originat…
Unknown·Acute myeloid leukaemia (AML)
Four patients with acute myeloid leukaemia (AML) died following administration of chemotherapy consolidation therapy that was delivered according to a protocol containing a critical error—specifying once-daily instead of…
28y · Female·aspiration of gastric contents complicating laxative abuse
A 28-year-old woman died from aspiration of gastric contents complicating severe laxative abuse. She fabricated a terminal cancer diagnosis to conceal anorexia nervosa and factitious disorder. During a RAH admission, a C…
93y · Female·blunt trauma with head injury on a background of ischaemic heart disease
Dorothy Mavis Baum, 93, died at Flinders Medical Centre from blunt trauma with head injury following an unprovoked assault by another nursing home resident with a plastic chain. Critical clinical failures occurred: the n…
45y · Female·Type 2 respiratory failure and aspiration pneumonia on a background of end-stage…
Leonie Jeisman, a 45-year-old woman with chronic obstructive pulmonary disease (COPD), schizoaffective disorder, obesity, and obstructive sleep apnoea, died from Type 2 respiratory failure and aspiration pneumonia. She w…
74y · Male·ischaemic heart disease; acute myocardial infarction due to significant atherosc…
A 74-year-old man with severe dementia died suddenly of ischaemic heart disease while detained at a secure mental health residential facility. He had been transferred to Clements House after his severe behavioural distur…
69y · Male·metastatic squamous cell carcinoma of the lung with chronic obstructive lung dis…
Barry John Matthews, aged 69, died of metastatic squamous cell carcinoma of the lung with chronic obstructive lung disease at an aged care facility while subject to a section 32 detention order. He had undergone chemothe…
83y · Male·cholangiocarcinoma on a background of advanced dementia and ischaemic valvular a…
Joseph McKenna, 83 years old, died of cholangiocarcinoma with advanced dementia and cardiac disease at an aged care facility where he was detained under a guardianship order. He was appropriately managed with palliative …
85y · Male·Pneumonia on a background of end stage Alzheimer's disease
Colin Dean Black, aged 85, died from pneumonia on a background of end-stage Alzheimer's disease at Repatriation General Hospital. He was admitted with agitated behaviour requiring mental health detention orders. His clin…
81y · Male·aspiration of gastric contents complicating disseminated moderately differentiat…
Graham Joseph Butson, aged 81, died from aspiration of gastric contents complicating undiagnosed metastatic lung cancer with brain metastases. He presented with confusion, agitation and atrial fibrillation; a lung mass w…
Female·Miranda Howard: aspiration pneumonia complicating overdose of prescription medic…
Two young women with borderline personality disorder (BPD) died by suicide after inadequate mental health care in South Australia. Miranda Howard (22) died from aspiration pneumonia following overdose; Aurora McPherson-S…
14y · Male·ventricular arrhythmia on a background of congenital aortic valve disease
A 14-year-old boy with congenital aortic stenosis collapsed and died from ventricular arrhythmia during football training in March 2015. He had undergone aortic valve repair in 2006 and was under long-term cardiology fol…
76y · Female·end-stage liver failure with encephalopathy due to hepatic cirrhosis
Wendy Marion Evans, aged 76, died from end-stage liver failure with encephalopathy due to hepatic cirrhosis. She presented with acute psychosis in February 2015 and was found to have extensive cerebrovascular disease, se…
16y · Male·Heat related illness in an individual with enterovirus D68 infection
Alexander Li, a 16-year-old with underlying enterovirus D68 infection, died of heat-related illness during a school bushwalking expedition in remote South Australia in extremely hot conditions (temperatures reaching 39.1…
94y · Male·general inanition on a background of advanced dementia
Leon McLaren Brown, 94 years old, died from general inanition (wasting) on a background of advanced dementia while a resident in aged care under Guardianship Board detention orders. He had been admitted to the facility f…
94y · Male·pneumonia on a background of severe dementia
Alfred Henry Cooper, a 94-year-old man with severe dementia, died of pneumonia at a nursing home where he was detained under a Guardianship Board order. His daughter raised concerns about nutrition during his final month…
79y · Male·aspiration pneumonia
Giuseppe Dilettoso, aged 79, died of aspiration pneumonia at a nursing home where he was detained under guardianship orders. He had suffered two significant head injuries (2000 and 2013), with the latter requiring emerge…
36y · Male·Hanging
Brian Matthew Roberts, aged 36, died by hanging while on home detention bail in Berri, South Australia on 22 March 2014. He had been charged with rape offences and was subject to bail conditions including electronic moni…
38y · Male·metastatic poorly differentiated carcinoma on a background of delirium and schiz…
Anthony Sissons, aged 38, died of metastatic renal carcinoma while under a Mental Health Act inpatient treatment order. He presented to hospital on three separate occasions (13-15 June 2012) with constipation, which was …
35y · Male·hypoxic-ischaemic encephalopathy (post cardiac arrest) on a background of acute …
A 35-year-old man died by hanging in a medium-security prison while on remand. He was found unresponsive in his cell with a ligature around his neck. Despite immediate CPR, transfer to hospital and transfer to ICU at Fli…
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