47 results
86y · Male·Aspiration Pneumonia secondary to Recurrent Colorectal Carcinoma
An 86-year-old man died from aspiration pneumonia following bowel preparation for elective colonoscopy. He was admitted to an outlying ward rather than the gastroenterology unit, where nursing staff documented multiple e…
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…
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…
57y · Female·Haemothorax following acute thoracic aortic dissection in a woman with congenita…
Sally Hopwood, 57, with Turner syndrome, coarctation of the aorta, and bicuspid aortic valve, presented to ED on 23 March 2012 with severe acute back and chest pain (8/10). A chest X-ray revealed widened mediastinum. She…
75y · Female·pyelonephritis and pneumonia
Molly Jessie Smith, a 75-year-old woman with longstanding severe mental illness, died of pyelonephritis and pneumonia on 16 August 2009. She had been in state psychiatric care continuously for 53 years. During her final …
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…
73y · Female·Multiple organ failure due to or as a consequence of sepsis due to or as a conse…
73-year-old woman died 12 days after elective colorectal surgery for synchronous caecal and rectal tumours. Post-operatively, she developed persistent low urine output and intermittent hypotension managed with repeated f…
75y · Male·left retroperitoneal haemorrhage associated with lumbar spine surgery
A 75-year-old man with complex comorbidities including Parkinson's disease and cognitive impairment underwent two-stage lumbar spine surgery for degenerative disc disease with stenosis. Post-operatively, he developed a r…
80y · Female·Gas embolism complicating surgical repair of an atherosclerotic aortic aneurysm …
An 80-year-old woman with multiple comorbidities (COPD, renal impairment, cardiac disease) underwent complex endoluminal repair of a thoracoabdominal aortic aneurysm at a private hospital. The procedure required use of C…
87y · Female·Multiple opioid drug toxicity (morphine and fentanyl) in combination with conges…
An 87-year-old woman with multiple comorbidities (ischaemic heart disease, emphysema, chronic kidney disease) was discharged home for palliative care after a hospital admission. Her family administered excessive doses of…
59y · Male·ischaemic heart disease due to coronary atherosclerosis; acute myocardial infarc…
A 59-year-old man with ischaemic heart disease, paranoid schizophrenia, unstable type 2 diabetes, peripheral vascular disease and chronic renal failure died of acute myocardial infarction while residing in aged care. He …
87y · Male·Strangulated small bowel due to adhesions from previous abdominal surgery
An 87-year-old man with diabetes, hypertension and dementia was admitted with presumed UTI and dehydration. Within 24 hours, nursing staff observed a distended abdomen and bile-stained vomiting—clinical signs of bowel ob…
46y · Female·Cardiac arrest of unknown origin
Virginia Brown, a 46-year-old Aboriginal woman, died of cardiac arrest of unknown origin on 31 October 2014 while detained under a Mandatory Residential Treatment (MRT) order at CAAAPU (Central Australian Aboriginal Alco…
86y · Male·Acute on chronic renal failure secondary to rhabdomyolysis as a consequence of d…
An 86-year-old man with chronic renal impairment (eGFR 37) died from acute-on-chronic renal failure secondary to rhabdomyolysis caused by a contraindicated drug interaction. His GP prescribed clarithromycin for a chest i…
35y · Male·intraperitoneal haemorrhage from an anastomotic leak from a transplanted renal a…
Luke Wood, a 35-year-old kidney transplant recipient, died 11 days post-transplant from intraperitoneal haemorrhage due to anastomotic leak from the transplanted renal artery. While post-operative inpatient care and init…
77y · Female·Venlafaxine toxicity in a woman with severe renal impairment and depression
77-year-old woman admitted to psychiatric ward with severe depression and catatonic features. Despite documented severe renal impairment and dehydration on admission, no medical review occurred over the weekend prior to …
56y · Female·hypoxic ischaemic encephalopathy due to inadvertent oesophageal intubation and f…
Sukanya Thurairajah, 55-year-old with multiple comorbidities including obesity, diabetes, coronary disease, and metastatic breast cancer, underwent haemodialysis at Canberra Hospital on 29 July 2011. She had an adverse r…
66y · Female·Multi-organ failure associated with haemorrhage and sepsis following cholecystec…
Mrs Jeanette Brown, 66, died from multi-organ failure following post-operative haemorrhage after elective laparoscopic cholecystectomy. Arterial clips applied to the cystic artery during surgery were inadequately secured…
90y · Female·Renal failure secondary to gentamicin therapy for urinary tract infection (sepsi…
Ellen O'Connor, a 90-year-old woman with renal artery stenosis and coronary artery disease, died from acute renal failure following gentamicin administration for Pseudomonas aeruginosa urinary tract infection. A single 2…
68y · Female·Massive blood loss due to disconnection of haemodialysis machine
Judith Heath, age 68, died from acute blood loss on 7 September 2006 at The Alfred Hospital during routine haemodialysis for end-stage renal failure. The Luer-Lok connection between her arteriovenous catheter and the hae…
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