62 results for “central line insertion”
74y · Male·Intra-abdominal haemorrhage complicating elective umbilical hernia repair
A 74-year-old man with significant cardiac history (atrial fibrillation, dilated cardiomyopathy, pacemaker) underwent elective umbilical hernia repair. Intraoperatively, unexpected ascites was discovered and partially dr…
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
…s and acute kidney injury); delayed and sub-optimal antibiotic dosing and timing; failure to place arterial line for continuous blood pressure monitoring; and critically, failure to admit to ICU despite severe sepsis wit…
69y · Female·Septic shock due to biliary peritonitis as a consequence of laparoscopic cholecy…
A 69-year-old woman died of septic shock following bile leak complications after laparoscopic cholecystectomy. Critical failures included: (1) inappropriate transfer to low-dependency unit on post-op day 1 despite consul…
41y · Male·large volume thrombotic stroke within the distribution of the right posterior ce…
A 41-year-old man with acute posterior circulation stroke was misdiagnosed as encephalitis despite normal lumbar puncture findings. The critical failure was Dr R.'s failure to diagnose stroke on 7 September and arrange u…
43y · Male·Multi-organ failure with coagulopathy secondary to acute exacerbation of chronic…
A 43-year-old man with a colloid cyst of the third ventricle presenting with progressive headache was admitted for planned endoscopic surgery. Surgery was delayed from Friday to Monday due to unavailability of specialist…
72y · Female·probable sepsis complicating chemotherapy for non-Hodgkin's lymphoma
A 72-year-old woman died of sepsis complicating chemotherapy for non-Hodgkin's lymphoma. She presented to ED with severe abdominal pain, elevated lactate (6.1 mmol/L), and signs of shock. The surgical team failed to reco…
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…
55y · Male·right intracerebral haemorrhage and left middle cerebral artery cerebrovascular …
Wayne Shore, 55, died from right intracerebral haemorrhage and left middle cerebral artery stroke complicating infective endocarditis, end-stage renal failure, and multiple myeloma. He was subject to a Level 1 Inpatient …
19y · Female·Meningococcal septicaemia
Emma McGrath, a 19-year-old nursing student, died from meningococcal septicaemia caused by the W strain after presenting to the ED with a 12-hour history of vomiting, diarrhoea, abdominal pain and fever. The atypical pre…
61y · Male·metastatic oesophageal neuroendocrine carcinoma
Terrence Wells, a 61-year-old prisoner, died from metastatic oesophageal neuroendocrine carcinoma in December 2018. Cancer was diagnosed in April 2018 after he reported difficulty swallowing, which was initially attribut…
32y · Female·Hypoxic-ischaemic encephalopathy due to hanging
Chloe Jane Campbell, aged 32, died by suicide while an involuntary inpatient with borderline personality disorder, complex PTSD, and chronic suicidal ideation. She was admitted 18-30 April 2019 after …
21y · Female·Multiple organ failure as a result of overwhelming Streptococcus pyogenes (Group…
… sepsis protocols with low thresholds (respiratory rate ≥20), ensure direct consultant access via dedicated lines, document all clinical advice, use telehealth for visual assessment, lower triage heart rate criteria to 1…
82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…
Winifred Carpenter, 82, died 11 days after a right hemicolectomy for colon cancer from peritonitis due to anastomotic leak. Critical failures occurred on discharge day (10 March 2023): clinicians did not recognize her de…
38y · Female·peritonitis with septic shock secondary to perforation of the gastrointestinal t…
… caused by perforation at the gastrostomy stoma site. The perforation likely occurred during difficult reinsertion of a dislodged PEG tube on 21 March 2001. Clinical lessons include: (1) A casual medical officer's asses…
77y · Female·Complications following a recent fracture and surgical repair of the right hip i…
…eveloped rapidly preoperatively and remained painful. The case illustrates that elderly patients with borderline organ reserve require close monitoring, lower threshold for infection suspicion, and protocolized periopera…
53y · Female·multiple organ failure as a result of septic shock
Pauline Kessell, aged 53, died from septic shock caused by overwhelming sepsis following endoscopic pyeloscopy with…
71y · Female·Ruptured abdominal aortic aneurysm, with coronary artery atherosclerosis contrib…
Sandra Cree, a 71-year-old woman, died from a ruptured abdominal aortic aneurysm (AAA) after undergoing an elective endovascular repair procedure in Brisbane. She presented to a remote hospital (Lightning Ridge Multi-Pur…
70y · Female·Tiger snake envenomation
…ials of antivenom within 2.5–4 hours of the bite at Royal Melbourne Hospital, consistent with national guidelines. Despite appropriate antivenom administration, she developed severe consumptive coagulopathy and life-thre…
66y · Female·Complications following paracetamol overdose
A 66-year-old woman died from complications of paracetamol overdose after ingesting Mersyndol (codeine/paracetamol combination tablets). She had developed dependence on over-the-counter Mersyndol over approximately 8 yea…
18y · Male·Multi organ failure due to sepsis from a Group A streptococcus infection
Alex Braes, an 18-year-old from Broken Hill NSW, died of multi-organ failure due to Group A streptococcus sepsis. He presented to Broken Hill Base Hospital three times over 24 hours with knee pain that progressed to seps…
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