445 results
45y · Male·Hypoxic-ischaemic encephalopathy due to prolonged hypoxia
A 45-year-old man died from hypoxic-ischaemic encephalopathy following cardiopulmonary arrest 11 hours after elective wrist plate removal surgery. Multiple contributing factors were identified: undisclosed obstructive sl…
70y · Female·Hypoxic/Ischaemic Encephalopathy consequent upon Cardiorespiratory Arrest and Co…
Beverly Ann Murphy, 70, underwent hysterectomy for endometrial carcinoma on 2 April 2008 at Royal Hospital for Women. The complex surgery was complicated by iatrogenic small bowel perforations. Post-operatively, wound de…
29y · Female·Hypoxic Encephalopathy consequent upon Cardiorespiratory Arrest arising from eit…
Helen Grainger, 29, with polycystic kidney disease and asthma, underwent pregnancy termination at Lambton Road Day Surgery in April 2007. She developed anaphylaxis post-procedure (likely cephalosporin-triggered) with car…
4y · Male·Complications of cutaneous thermal burn injuries
Abdullah Kocoglu, age 4, died from complications of severe thermal burn injuries sustained in a house fire on 14 February 2011 at his grandparents' home in Hampton Park, Victoria. The fire was ignited when Abdullah playe…
0y · Female·Perinatal asphyxia
Summer Elizabeth Rose Niehoff died from perinatal asphyxia hours after vaginal birth following a prolonged labour in hospital. The coroner found multiple clinically preventable failures: escalation of oxytocin augmentati…
75y · Female·hypovolaemic shock from excessive blood loss
Lorraine McDonald, age 75, died from hypovolaemic shock due to massive intraoperative bleeding during an anterior resection for rectosigmoid adenocarcinoma. Critical deficiencies included: no pre-admission clinic assessm…
Unknown·Ms Choi: hypoxic brain damage due to drowning/immersion due to rafting accident;…
Two language students died following a white water rafting incident on the Tully River. A collision between rafts diverted one raft into a hazardous channel, causing it to strike Sieve Rock and flip. Both occupants becam…
64y · Male·Postoperative intra-abdominal bleeding from pancreatic artery injury and its con…
John Reginald Beech, 64, died at Sydney Adventist Hospital on 24 April 2007 from postoperative intra-abdominal hemorrhage following colonic surgery. One week earlier, he underwent high anterior resection and hernia repai…
34y · Male·Air embolism and severe haemorrhage due to perforation of the right subclavian v…
Darryl Smith, aged 34, died following emergency surgery for a fractured clavicle at Sunnybank Private Hospital. During the final drilling of the sixth screw hole, the surgeon's drill penetrated the underlying right subcl…
56y · Male·Cardiogenic shock, end stage ischemia due to chemo related cardiomyopathy, fulmi…
Andrew Westley, 56, underwent heart transplantation at The Alfred Hospital for dilated cardiomyopathy secondary to chemotherapy for Hodgkins lymphoma and prior cardiac surgery. The procedure involved a 9-hour ischaemic t…
2y · Male·Group A Streptococcal toxic shock syndrome which probably originated in the thro…
Ryan Saunders, a 2-year-old boy, died from Group A Streptococcal toxic shock syndrome after a 72-hour presentation with fever, pain, and systemic illness. Initial GP care was appropriate given the presentation and diagno…
40y · Male·drug overdose (propofol)
Stuart Hill, a 40-year-old anaesthetic and recovery nurse at the Alfred Hospital with a history of anxiety and depression, died by intentional drug overdose using propofol and rocuronium obtained from his workplace. Foll…
34y · Female·Catastrophic post-partum haemorrhage following caesarean delivery, secondary to …
A 34-year-old Vietnamese woman died from catastrophic postpartum haemorrhage following an elective caesarean delivery. Placenta accreta was discovered intraoperatively and managed with blood transfusion, uterotonic agent…
78y · Male·Complications of bowel surgery; specifically post-operative chest infection and …
Barry Howroyd, a 78-year-old man, underwent routine colonoscopy on 7 August 2008 which complicated a known bowel carcinoma diagnosis. The procedure caused bowel perforation, diagnosed the next day via CT imaging. Surgica…
8y · Male·Septic shock consequent on burst appendix with peritonitis
Jacob Belim, aged 8, presented to a GP with appendicitis on 24 March 2009 but the diagnosis was missed. The next day, his treating doctor correctly diagnosed ruptured appendix and referred him urgently to hospital. At Li…
Female·Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perfor…
Two elderly women died following vaginal prolapse surgery performed by the same surgeon, Dr O., with similar mechanisms: bowel perforation leading to peritonitis and sepsis. Mrs Leonard (77) underwent laparoscopic surger…
0y · Female·Hypoxic ischaemic encephalopathy due to true knot in umbilical cord
A term infant died from hypoxic ischaemic encephalopathy caused by a true knot in the umbilical cord. The mother presented in labour with spontaneous rupture of membranes and had a prolonged second stage. Foetal heart ra…
40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…
Michael Peter Magro, a 40-year-old male inmate at a correctional facility, died on 27 December 2008 from hypoxic brain injury following cardiac disease and severe pneumonia. Critical failures in prison healthcare were id…
0y · Male·Hypovolemic shock, metabolic acidosis and coagulopathy in association with subga…
Owen Appleby, born at Portland Hospital after labour induction, developed hypovolemic shock and died at Warrnambool Hospital 17 hours after birth. Ventouse extraction was used to assist delivery; he was born with low APG…
68y · Female·Multi-organ failure associated with septic shock following duodenal perforation …
Athenia Hana Walden, 68, died from multi-organ failure and septic shock following duodenal perforation during laparoscopic surgery at Swan District Hospital on 8 May 2008. Surgery was performed to remove her gallbladder,…
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