445 results
81y · Female·Severe cardiogenic shock complicating cardiac surgery
An 81-year-old woman died of severe cardiogenic shock following elective aortic valve replacement complicated by intraoperative haemodynamic instability and inadequate postoperative ICU management. The surgery involved e…
47y · Male·cardiomyopathy in a 47 year old man with Down syndrome
Greg Norman Mackrell, a 47-year-old man with Down syndrome and known cardiomyopathy with pacemaker, was admitted for elective colonoscopy. The anaesthetist reviewed him preoperatively and the procedure was completed quic…
Female·Combination of liver failure, blood loss and shock following needle biopsy
Alyssa, a 9-week-old infant, died from hemorrhage following a liver biopsy at Monash Medical Centre. She had persistent jaundice, and biopsy was undertaken to investigate potential biliary atresia. Post-operatively, nurs…
59y · Female·sepsis due to faecal peritonitis due to perforation of sigmoid colon complicatin…
A 59-year-old woman died from sepsis due to faecal peritonitis following a bowel perforation during laparoscopic oophorectomy for a benign ovarian cyst. The perforation was repaired during the initial surgery, but the re…
77y · Female·Intracranial haemorrhage suffered during the course of neurosurgery
Oi Fong Chan, a 77-year-old woman, underwent endoscopic trans-nasal pituitary surgery at Concord Hospital on 8 December 2006 to remove a benign pituitary adenoma. During the operation, the surgical team inadvertently enc…
12y · Female·Raised intracranial pressure due to acute-on-chronic hydrocephalus in the contex…
Samantha Rose Spence, 12 years old, died two days after spinal fusion surgery for severe scoliosis. She had a pre-existing, asymptomatic Chiari type 1 malformation detected on pre-operative MRI of her spine. A paediatric…
Male·Myocardial failure resulting from excessive pulmonary blood flow and consequenti…
One-month-old Liam Woodcock, born extremely prematurely at 27.5 weeks gestation weighing approximately 1 kilogram, died from myocardial failure secondary to excessive pulmonary blood flow in the context of severe congeni…
26y · Female·Complications of liposuction surgery: sepsis, decreased respiratory function sec…
Lauren James, a 26-year-old woman, died from complications of elective liposuction surgery performed on 19 January 2007. She presented to the clinic on 22 January with severe pain and asymmetrical swelling of her left th…
68y · Female·Presumed septic shock with multiple organ failure secondary to acute suppurative…
A 68-year-old woman died from septic shock and multi-organ failure secondary to acute suppurative appendicitis complicated by recent peritoneal adhesion division. Admitted on 31 March 2005 with acute abdominal pain, she …
68y · Female·Anaphylactoid reaction to intravenous CT scan contrast medium leading to cardior…
A 68-year-old woman with asthma presented to hospital with abdominal pain suggestive of biliary obstruction. A CT scan with intravenous contrast was ordered to clarify the diagnosis before potential surgical transfer. Sh…
Female·retroperitoneal blood loss in a setting of anticoagulation therapy following hip…
Valerie Kolts died from retroperitoneal blood loss following hip replacement surgery while on anticoagulation therapy. The coroner found no lack of care contributed to her death. Although some clinical signs were retrosp…
39y · Female·heart failure connected to a massive pulmonary embolus as a result of deep vein …
A 39-year-old woman died from acute heart failure due to massive pulmonary embolus from deep vein thrombosis two days after laparoscopic appendicectomy. She presented to ED with abdominal pain and nausea, was diagnosed w…
60y · Female·Penetrating injury of the descending thoracic aorta complicating spinal stabiliz…
A 60-year-old woman died from a penetrating injury to the descending thoracic aorta sustained during spinal stabilisation surgery for a T12 burst fracture. During pedicle cannulation, the surgical awl fractured the left …
20y · Male·hypoxic encephalopathy
Matthew Lynn, aged 20, died from hypoxic encephalopathy after sustaining head injuries in a motor vehicle collision. While hospitalised in ICU, his endotracheal tube (ETT) became displaced around 12:20am on 23 January 20…
75y · Female·Septicaemia as a result of lobar pneumonia; congestive heart failure also presen…
A 75-year-old woman died from septicaemia following a percutaneous tracheostomy procedure performed by a locum consultant on a Sunday. The procedure deviated significantly from the established ICU protocol: it was perfor…
58y · Female·acute peritonitis, which led to the development of acute septicaemia following a…
A 58-year-old woman died from acute peritonitis and sepsis following surgery for duodenal diverticulum. Initial elective surgery on 4 March 2008 was technically successful, but the patient deteriorated with suspected com…
82y · Female·Complications from hypoglycaemic brain damage and cerebral vascular accident
Margaret Allan Johnston, 82-year-old admitted for UTI and confusion, was found comatose on 4 September 2006 with severe hypoglycaemia (glucose 0.8 mmol/L) despite being non-diabetic. Blood tests revealed high insulin and…
Female·meconium aspiration
Talisha Hildebrandt was stillborn at Ayr Hospital on 7 January 2007 due to meconium aspiration. The pregnancy was low-risk and managed appropriately. A CTG monitor showed concerning fetal heart rate changes, prompting ur…
17y · Male·fatal asphyxia resulting from severe upper airway obstruction secondary to acute…
Kieran Watmore, a fit 17-year-old male, died from fatal asphyxia at Albany Regional Hospital on 28 August 2008 while being treated for acute tonsillitis. He presented to ED on 27 August with severe throat pain and was pr…
29y · Female·Multisystem organ failure following postpartum haemorrhage due to atonic uterus
Rebecca Murray, 29, died from multisystem organ failure following postpartum haemorrhage after an emergency caesarean section at Bathurst Base Hospital on 24–25 June 2007. The coroner found her death preventable. Key cli…
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