61 results
68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…
Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mi…
64y · Male·Left-sided intracerebral haemorrhage associated with deep brain stimulator wire …
A 64-year-old man died from intracerebral haemorrhage along a deep brain stimulator wire tract four days after elective neurosurgery for essential tremor. He was readmitted on day 4 with suspected stroke and started on t…
75y · Male·cerebral metastatic malignancy (lung cancer with brain metastases)
Kenneth Ballard, aged 75, died in prison custody from cerebral metastatic lung cancer. He had been diagnosed with chronic lymphocytic lymphoma in 2012 and managed at Mount Gambier Prison. In late 2014, Mr Ballard refused…
86y · Male·combined effects of acute myeloid leukaemia, acute renal failure and staphylococ…
Patrick Lawrence Walsh, aged 86, died in custody at Royal Adelaide Hospital from combined acute myeloid leukaemia, acute renal failure, and staphylococcal pneumonia. He had a significant medical history including ischaem…
21y · Female·pulmonary embolism in association with deep vein thrombosis of the left leg
A 21-year-old woman died from pulmonary embolism associated with deep vein thrombosis following ankle fracture surgery and immobilisation. She was discharged without thromboprophylaxis despite multiple VTE risk factors (…
5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …
A five-year-old child with complex neurodevelopmental conditions and polypharmacy (including valproic acid for epilepsy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with ora…
85y · Female·sepsis, with aspiration pneumonitis being an antecedent cause. Iatrogenic injury…
Lorraine Barnes, an 85-year-old woman admitted to Wollongong Private Hospital for convalescence, died from sepsis with aspiration pneumonitis following iatrogenic lung injury. She developed severe malnutrition and electr…
87y · Female·left frontal temporal subdural haematoma following closed head injury sustained …
An 87-year-old woman on irreversible anticoagulation suffered a subdural haematoma from a fall. She presented to a community hospital lucid with stable vitals. A CT scan confirmed acute subdural haematoma. The neurosurgi…
35y · Female·Unascertained
A 35-year-old grand multipara with multiple risk factors (BMI >35, smoking, grand multiparity, pregnancy-induced hypertension) presented at 40+4 weeks with absent foetal movements and was induced on Sunday evening. She e…
16y · Male·pulmonary embolism secondary to nephrotic syndrome
Dylan Riley, a 16-year-old with steroid-responsive minimal change nephrotic syndrome, died from a massive pulmonary embolism (PE) on 1 August 2015. He presented to Rockingham Hospital with dyspnoea, hypoxia, tachycardia …
50y · Male·Head injuries due to motor vehicle accident
A 50-year-old traffic controller was struck and killed by a motor vehicle driven by a woman with multiple serious medical conditions (end-stage renal disease, multiple myeloma) who was taking Panadeine Forte. The driver …
Unknown·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…
58y · Male·Complications of chemotherapy for the treatment of Hodgkin lymphoma
Mettaloka Halwala, 58, died from complications of bleomycin toxicity during Hodgkin lymphoma chemotherapy. A PET scan on 11 November 2015 showed widespread lung uptake suggestive of bleomycin pneumonitis, but the haemato…
79y · Female·Rhabdomyolysis in a woman with multiple myeloma and renal impairment
Margaret Ann Yeomans, aged 79, died from rhabdomyolysis in the context of multiple myeloma and chronic renal impairment. A critical medication error occurred when rosuvastatin 40mg was dispensed instead of her prescribed…
50y · Male·Multiple pulmonary thromboemboli due to deep vein thrombosis following pharyngea…
A 50-year-old man died from pulmonary thromboembolism following uvulopalatopharyngoplasty (UPPP) surgery for obstructive sleep apnoea. Critical failures in post-operative management at a private hospital included: failur…
59y · Female·Multiorgan failure and polymicrobial sepsis secondary to severe bone marrow fail…
A 59-year-old woman with renal transplant died from multiorgan failure and sepsis secondary to severe bone marrow failure caused by azathioprine toxicity. She had an undiagnosed genetic polymorphism (TPMT *3A/*3A homozyg…
78y · Female·multi-organ failure due to haemorrhage into the abdomen, pelvis and retroperiton…
78-year-old Jehovah's Witness died from multi-organ failure secondary to intra-abdominal and retroperitoneal haemorrhage following extensive anterior and posterior lumbar spinal fusion surgery. The patient had multiple c…
63y · Female·unable to determine; possibly mirtazapine toxicity, cardiac disease, or injectio…
Sue Denise Allie, aged 63, died at home in July 2015. She had presented to hospital in May 2015 with superwarfarin (brodifacoum) poisoning from rat poison, which she attributed to handling contaminated material. Medical …
84y · Male·Acute myocardial infarction precipitated by upper gastrointestinal haemorrhage f…
An 84-year-old man with multiple comorbidities was prescribed rivaroxaban for deep vein thrombosis despite being a practicing Jehovah's Witness who refused blood transfusions. Rivaroxaban cannot be monitored or reversed,…
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