34 results for “central venous line insertion”
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…
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…
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…
24y · Male·Multiple organ failure due to or as a consequence of severe thermal burns
Omid Masoumali, a 24-year-old Iranian refugee detained on Nauru under Australian offshore processing arrangements, suffered severe thermal burns (>50% TBSA) on 27 April 2016 after self-immolating at the Nibok settlement.…
11y · Male·Sepsis
An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…
38y · Male·Pulmonary thromboembolism due to bilateral deep calf vein thrombi
A 38-year-old man with schizo-affective disorder, bipolar disorder, and asthma presented to the emergency department with presumed pneumonia based on fever, pleuritic chest pain, and respiratory symptoms. His general pra…
62y · Female·Haemorrhage caused by abdominoperineal excision of the rectum
A 62-year-old woman died of uncontrollable haemorrhage following an abdominoperineal excision of the rectum (APER) at a remote hospital. The coroner found the operation itself was inappropriate: performed for undiagnosed…
29y · Female·multi-lobe community acquired pneumonia and respiratory failure
Clare Louise Harrison, a 29-year-old woman with long-standing anorexia nervosa diagnosed at age 17, died from community-acquired pneumonia and respiratory failure after a final 21-day admission to Alice Springs Hospital.…
57y · Female·Intra-abdominal Haemorrhage following Appendectomy, with contributing factor of …
A 57-year-old woman with COAD, hypertension, and unrecognized severe coronary atherosclerosis presented with appendicitis. Surgery was performed by an unsupervised surgeon operating on friable tissues with limited visibi…
62y · Female·Hypovolaemic and cardiogenic shock (hysterectomy) in the context of cardiomegaly…
A 62-year-old woman with significant comorbidities (cirrhosis, cardiomegaly, thrombocytopenia, chronic kidney disease, COPD) died from hypovolaemic and cardiogenic shock during elective total laparoscopic hysterectomy fo…
33y · Male·lobar pneumonia (Streptococcus pneumonia with septic shock)
Owen King, a 33-year-old Aboriginal man, died of lobar pneumonia on 24 June 2002 at Alice Springs Hospital following brief police custody for alleged intoxication. He was apprehended twice on 23 June under protective cus…
63y · Male·pneumonia complicating anoxic brain injury, due to post-operative haemorrhage as…
…g ileostomy closure surgery. The critical failure was a 2.5-hour delay (0530-1100 hours) in obtaining intravenous access and blood results that would have revealed a dropped haemoglobin from 130 to 75. Early signs of hyp…
32y · Female·Cardiac arrest due to hypoxia caused by dynamic hyperinflation arising from comp…
A 32-year-old woman with Sponastrime Dysplasia (a rare genetic bone disorder) died during elective bariatric surgery. She had undiagnosed subglottic stenosis (airway narrowing) and tracheobronchomalacia. Critical clinica…
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