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QLDhospital2017-10-06

Parsons, Ann

59y · Female·Global cerebral oedema due to hypoxic cerebral ischaemia following cardiac arres…

59-year-old woman admitted with newly diagnosed grade 4 glioblastoma underwent surgery 16 days later after delays during consultant's planned leave. Post-operative complications included ischaemic stroke confirmed on ima…

neurosurgeryintensive carediagnosticcommunicationdexamethasone
QLD2017-10-04

Wlodarczyk, Julian Werner

62y · Male·drowning/immersion due to multiple drug intoxication (methamphetamine, diazepam,…

Julian Wlodarczyk, a 62-year-old, drove off the Daintree River Ferry into the water after midnight on 30 April 2013 and drowned. Autopsy showed multiple drug intoxication (methamphetamine at potentially lethal levels, di…

occupational and environmental healthforensic medicinesystemcommunicationmethamphetamine
QLDhospital2017-09-20

Mrs R-W - Non-inquest findings

83y · Female·Hyponatraemic encephalopathy due to adverse effects of citaprolam and duloxetine…

An 83-year-old woman with pre-existing SIADH-related chronic hyponatraemia died from hyponatraemic encephalopathy following antidepressant therapy. Critical clinical lessons include: (1) the importance of accessing prior…

general medicineemergency medicinediagnosticmedicationcitalopram
QLDhospital2017-09-20

Mr TAM - Non-inquest findings

62y · Male·Multi-organ infarctions (brain, kidneys, heart) resulting from thromboemboli sec…

Mr TAM, a 62-year-old man with multiple cardiac conditions, died from multi-organ infarction secondary to an atrio-oesophageal fistula that developed after radio-frequency ablation for atrial fibrillation. The fistula is…

cardiologycardiothoracic surgerycommunicationsystem
QLDaged care2017-09-20

Mr RO'H - Non-inquest findings

69y · Male·septic shock due to infected decubitus ulcers complicated by osteomyelitis

A 69-year-old man with Parkinson's disease died from septic shock caused by infected pressure ulcers (stage 4 decubitus ulcers with osteomyelitis) that developed in aged care. Pressure sores appeared within 31 days of ad…

geriatric medicinegeneral practicediagnosticsystemdicloxacillin
QLDcommunity2017-09-14

John, Timothy

22y · Male·Hanging

Timothy John, age 22, died by hanging 8 days after commencing varenicline (Champix) for smoking cessation. He had a documented history of depression, anxiety, and substance abuse, with prior attempted suicide. His GP, Dr…

general practicepsychiatrydiagnosticcommunicationvarenicline
QLD2017-09-11

Mr D

36y · Male·mixed drug toxicity including heroin and methamphetamine

A 36-year-old man with a history of intravenous drug use died from mixed drug toxicity involving heroin and methamphetamine. He was recently released on parole and appeared to be reintegrating successfully. During a trip…

forensic medicinetoxicologyheroin
QLDhospital2017-09-07

Mr R - Non-inquest findings

63y · Male·Multiple injuries due to fall from height

A 63-year-old man with Parkinson's disease died by suicide three days after discharge from hospital following reimplantation of a Deep Brain Stimulation (DBS) device. His initial DBS surgery in 2013 was successful, but d…

neurosurgeryneurologysystemcommunicationcitalopram
QLDhospital2017-09-02

ML - Non-inquest findings

71y · Female·Haemothorax and haemopericardium secondary to ruptured dissecting aneurysm of th…

A 71-year-old woman with hypertension and prior myocardial infarction presented to emergency with sudden chest pain, jaw pain, and syncope. Aortic dissection was appropriately suspected and a contrast CT-aortagram was pe…

emergency medicinecardiologydiagnosticsystemintravenous fluids
QLDhospital2017-08-29

Mr C - Non-inquest findings

87y · Male·Endobronchial and pulmonary haemorrhage secondary to pneumonia complicating chro…

An 87-year-old man with atrial fibrillation on warfarin underwent elective bronchoscopy for suspected lung lesion. The admitting respiratory team incorrectly documented a mechanical aortic valve replacement when he actua…

respiratory medicinecardiologydiagnosticcommunicationwarfarin
QLDcommunity2017-08-17

JJKD - Non-inquest findings

34y · Male·drowning

A 34-year-old man with schizoaffective disorder drowned after attempting to surf in dangerous conditions on 31 December 2015. He had been under community mental health care with fragmented coordination between public and…

psychiatrycommunicationsystemclozapine
QLD2017-08-04

Mrs H - Non-inquest findings

76y · Female·Acute renal failure due to dehydration due to upper gastrointestinal bleed

A 76-year-old woman with chronic pain was admitted to a small rural hospital on 1 April 2015 with haematemesis secondary to NSAID use. Blood tests were ordered on admission but not transported to the district hospital fo…

general medicinegastroenterologydiagnosticcommunicationibuprofen
QLDhospital2017-07-31

Mrs NSM - Non-inquest findings

81y · Female·left haemothorax and mediastinal haemorrhage from the insertion site of the perm…

An 81-year-old woman died from haemothorax and mediastinal haemorrhage following pacemaker insertion for sick sinus syndrome. Multiple venous punctures during the procedure caused vascular injury. Critical clinical lesso…

cardiologyintensive carediagnosticcommunicationglyceryl trinitrate
QLDcommunity2017-07-26

Stephenson, Ethan

14y · Male·Head injuries resulting from a motor vehicle collision (pedestrian)

A 14-year-old boy, Ethan Stephenson, was struck by a four-wheel drive vehicle while skateboarding on Russell Island in June 2014 and died from head injuries. The driver was speeding (above 60km/h limit), intoxicated (est…

forensic medicinesystemdelay
QLDhome2017-07-26

Richards, Karen Louise

41y · Female·mixed drug and alcohol toxicity

Karen Louise Richards, 41 years old, died from mixed drug and alcohol toxicity on 11 January 2014. She had consumed heroin (evidenced by 6-MAM metabolite), alcohol, benzodiazepines, and other prescription medications. He…

psychiatryemergency medicinedelaysystemheroin
QLDcommunity2017-07-24

Thwaites, Andrew John

Male·carbon monoxide poisoning causing unconsciousness underwater and drowning

Andrew John Thwaites, an experienced recreational scuba diver with over 300 dives, died from carbon monoxide poisoning and drowning during a dive at Cherubs Cave, Henderson Rock, Moreton Bay on 10 August 2016. His cylind…

system
QLDhospital2017-07-18

Stimpson, Reginald - Non-inquest findings

73y · Male·Acute intracranial haemorrhage, due to or as a consequence of coagulopathy, due …

Mr Stimpson, a 73-year-old man, died from massive intracerebral haemorrhage secondary to coagulopathy caused by inadvertent double administration of anticoagulants (Clexane and Xarelto). He developed bilateral pulmonary …

orthopaedic surgerygeneral medicinemedicationcommunicationenoxaparin
QLD2017-07-11

Hooper, Troy Ronald - Non-inquest findings

24y · Male·Penetrating head injury due to industrial accident involving explosion and eject…

Troy Ronald Hooper, a 24-year-old labourer, died from a penetrating head injury caused by an exploding gas strut during removal of a prototype boat rack at his workplace. The incident occurred because the boat rack was p…

diagnosticprocedural
QLDhospital2017-06-28

Tonkin, Nixon Martin

0y · Male·Head injuries (birth trauma) secondary to obstructed labour and fetal macrosomia…

Nixon Martin Tonkin died from head injuries sustained during caesarean delivery for obstructed labour at 38 weeks gestation. The infant's head became deeply impacted in the maternal pelvis after prolonged second-stage la…

obstetricsanaesthesiadiagnosticcommunicationoxytocin
QLDhospital2017-06-28

Langley, Archer

0y · Male·Amniotic fluid aspiration (severe); with contribution from thin umbilical cord a…

Archer Langley died at age 1 hour from severe amniotic fluid aspiration following delivery by emergency caesarean section for obstructed labour. His mother's labour was prolonged and difficult, but critical delays occurr…

obstetricsneonatologydiagnosticcommunicationprostin
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