64 results for “x-ray examination”
72y · Male·Complications of subtotal colectomy for diffuse polyposis and invasive adenocarc…
Melvin Lynch, aged 72, died in custody at Prince of Wales Hospital on 9 December 2019, nine days after elective subtotal colectomy for bowel cancer. Post-operatively, he developed complications including pleural effusion…
35y · Male·intra-abdominal haemorrhage caused by ruptured spleen
…severe chest pain, profuse sweating, shaking, vomiting and a history of passing black blood per rectum. Examination revealed tachycardia (pulse 160) and hypertension (160/100). The GP diagnosed pleurisy, prescribed anal…
4y · Male·acute suppurative peritonitis following rupture of an inflamed vermiform appendi…
…cy with vomiting and fever. Appendicitis was considered as a primary diagnosis from admission. Clinical examination was challenging due to communication difficulties, but findings were initially concerning then appeared…
54y · Male·Pneumonia due to Staphylococcus aureus
A 54-year-old man died in custody from Staphylococcus aureus pneumonia. Over 11 days before death, he presented multiple times with respiratory symptoms and requested antibiotics, but was never seen by a doctor. Key clin…
23y · Female·chronic hydrocephalus with brain swelling
…us presented to the ED with neck pain, headache and vomiting. Dr B. assessed her briefly without formal examination or detailed history, prescribed ketorolac and diazepam, and discharged her after she vomited. She died …
59y · Male·Combined effects of acute on chronic pneumonia and pulmonary thromboembolism
A 59-year-old man with intellectual disability and minimal verbal communication died from acute on chronic pneumonia and pulmonary thromboembolism. He had a long history of recurrent UTIs, chest infections, and significa…
50y · Male·Pneumonia
…, he deteriorated rapidly with vomiting, altered consciousness, and severe pneumonia ('white out' on chest X-ray), requiring intubation and ICU admission. He died the same day. The coroner found that while the transfer …
73y · Female·coronary atherosclerosis
A 73-year-old woman admitted with severe respiratory distress was appropriately managed in ICU with intubation and extubated after 8 days. She was transferred to coronary care as stable but deteriorated with cardiorespir…
67y · Female·bronchopneumonia complicating disseminated pulmonary large cell carcinoma with r…
Nancy McCarthy, 67, presented with progressive back and chest pain initially attributed to vertebral compression fracture. She deteriorated acutely with confusion, agitation, and respiratory distress, necessitating Menta…
73y · Male·Lung cancer (squamous cell carcinoma)
Robert Skilton, aged 73, died of advanced squamous cell carcinoma of the lung while in prison custody. He had a 59-year smoking history and consistently declined medical care throughout 43 years of incarceration, with up…
74y · Female·haemothorax secondary to dissecting thoracic aorta
… onset pain with characteristics atypical of musculoskeletal pain. Investigation limitations (normal chest x-ray, normal blood pressure) were misused to exclude the diagnosis. The case reveals systemic issues including …
56y · Male·pulmonary thromboembolism due to left deep vein thrombosis
A 56-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis. He presented to his GP on 20 January 2017 with persistent dyspnoea and chest pain following a 22-hour flight to Greece and respirat…
30y · Male·Haemopericardium caused by ruptured dissecting thoracic aortic aneurysm
Joel Frigo, 30-year-old with Marfan's syndrome, presented to a regional hospital with chest pain and was diagnosed with a chest infection/pleurisy. He died from a ruptured dissecting thoracic aortic aneurysm with haemope…
79y · Female·Dilated cardiomyopathy with decompensated heart failure not appropriately treate…
…es: Dr K.'s initial assessment focused narrowly on chest pain, missing the opportunity to review the chest X-ray showing pleural effusions and to communicate the significantly reduced ejection fraction to the managing t…
81y · Male·aspiration of gastric contents complicating disseminated moderately differentiat…
Graham Joseph Butson, aged 81, died from aspiration of gastric contents complicating undiagnosed metastatic lung cancer with brain metastases. He presented with confusion, agitation and atrial fibrillation; a lung mass w…
31y · Male·Complications in association with intestinal volvulus
31-year-old Morgan Edwards with Smith-Magenis Syndrome, cerebral palsy and Crohn's disease was discharged from Fiona Stanley Hospital ED on 14 August 2018 without definitive diagnosis despite elevated respiration rate, u…
82y · Female·acute peritonitis, ruptured bowel and incarcerated bowel herniation
…s attributed to narcotic medication. Dr H., an intern, examined her twice but did not perform abdominal examination and did not escalate to senior surgical staff. The deceased died from acute peritonitis due to ruptured…
16y · Male·Peritonitis as a result of ruptured duodenum following blunt trauma of the torso
…gnostic error (missing internal abdominal injury), failure to escalate to senior clinicians, inadequate examination technique (in a wheelchair), poor handover and documentation, and lack of proper discharge instructions…
72y · Male·sepsis of undetermined source (pneumonia or spinal epidural abscess)
…s. Despite these findings, he was discharged without vital signs being rechecked or documented, without examination by the discharging doctor, and without septic workup or imaging. Hours later he collapsed with septic s…
58y · Male·complications of large bowel pseudo-obstruction
Paul Desmond Smith, aged 58, died from complications of large bowel pseudo-obstruction following discharge from hospital after inadequate assessment. He had presented to the ED with lower abdominal pain and severe faecal…
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