435 results for “renal failure”
48y · Male·myocardial infarction due to ischaemic heart disease due to hypertension
…rction due to ischaemic heart disease and hypertension shortly after undergoing urology surgery. Critical failures in clinical communication prevented recognition of undiagnosed angina before surgery. The patient presen…
68y · Male·Complications following colon surgery on a background of cirrhosis of the liver;…
…ations became apparent. An anastomotic leak required emergency surgery on 9 June, but by then multi-organ failure had developed. The coroner recommended comprehensive guidelines for perioperative assessment and manageme…
41y · Male·exsanguination (hypovolemic shock complicating acute blood loss) due to fistula …
…, died on 26 June 2019 from exsanguination due to internal bleeding (ureter-iliac artery fistula or steady renal/bladder bleed). He fell at his supported residential unit on the morning of death, reporting dizziness and…
2y · Male·Tramadol toxicity in the setting of adenotonsillectomy in a child with Pierre Ro…
…eizures, and severe hypoxic-ischaemic brain injury, leading to death despite intensive care. Key clinical failures included: the prescribing doctor not specifying tablet/capsule formulation despite knowing oral drops po…
74y · Female·Diabetic ketoacidosis
…ood glucose levels remained persistently elevated (>33 mmol/L) despite escalating insulin doses. Critical failures included: inadequate monitoring of vital signs and ketones; lack of 'sick day' management protocols; no …
74y · Male·cardiac arrhythmia in an elderly man with chronic obstructive pulmonary disease …
Ian Head, a 74-year-old man with chronic obstructive pulmonary disease, hypertension, and chronic kidney disease, died from cardiac arrhythmia following COVID-19 infection while imprisoned at Acacia Prison. He had receiv…
55y · Female·Multiple drug toxicity in a woman with coronary artery atherosclerosis
A 55-year-old woman with complex medical history including chronic pain, previous multiple abdominal surgeries, gastrointestinal disorders, mental health issues including DID, and suicidal ideation died from multiple dru…
69y · Female·Septic shock due to biliary peritonitis as a consequence of laparoscopic cholecy…
…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 consultant's undocu…
85y · Female·Multisystem failure complicating ischaemic heart disease and ischaemic bowel in …
…xfield, 85, died 5 days after elective left total knee replacement at a private hospital from multisystem failure due to ischaemic heart disease and ischaemic bowel. Critical clinical lessons: (1) Multiple abnormal vita…
76y · Male·Multiple organ failure due to sepsis with peritonitis and pancreatitis, secondar…
A 76-year-old man died from multiple organ failure following an ERCP procedure for gallstone removal. The procedure itself was appropriate and uneventful. P…
74y · Male·Aspiration of gastric contents due to paralytic ileus following Whipple surgery …
William Searle, a 74-year-old prisoner, died from aspiration of gastric contents following a Whipple procedure for recurrent ampullary adenoma. The clinical lessons involve recognition of gastroparesis risk in high-risk …
65y · Male·Cardiac arrhythmia, probably Torsades de Pointes, due to the combined effects of…
…idone and Ciprofloxacin, both QT-prolonging drugs. Mr Phillips should have been admitted as an inpatient. Failures included: inadequate communication between doctors, ignorance of drug interactions, lack of proper escal…
Female·Burns due to gas explosion due to motor vehicle collision with building
…ally unfit to drive and should not have held an unconditional licence. Key preventability factors include failure of the GP to reinforce non-driving advice after the 2009 seizure, inadequate follow-up on recommended inv…
65y · Female·Liver failure secondary to paracetamol toxicity
A 65-year-old retired nurse died from paracetamol toxicity and liver failure after taking excessive paracetamol tablets for pain relief following a fractured arm. She presented to ho…
20y · Male·exertional heat stroke
…entilated facility (Dojo) while dehydrated. He developed seizures, hyperthermia (41.9°C), and multi-organ failure. The coroner found the training was inappropriate given his fitness level, without heat stress index meas…
86y · Male·Cardiac arrest triggered by electrolyte imbalance and sepsis secondary to compli…
…s deteriorating condition. The hernia recurred or was incompletely reduced within 30 hours. Coroner found failures in GP assessment depth, documentation of clinical instructions, and nursing responsibility for recognizi…
82y · Male·Cardiomegaly, myocardial fibrosis and ischaemic coronary artery disease in the c…
…wel burns and colonic perforation, necessitating emergency surgery. He subsequently died from multi-organ failure in the context of his pre-existing severe cardiovascular disease (cardiomegaly, myocardial fibrosis, trip…
76y · Female·multiple organ failure due to abdominal wall cellulitis (surgically treated)
… a 76-year-old obese woman with multiple comorbidities in residential aged care, died from multiple organ failure secondary to abdominal wall cellulitis. A critical care failure occurred when an old dressing left in an …
12y · Female·acute septicaemia resulting from osteomyelitis of the left femur
… visits, conduct three-monthly case reviews, and properly re-register the foster carer. Multiple systemic failures—inadequate staffing, poor information systems, failure to recognise cumulative harm, and assumption that…
59y · Female·complications of intra-abdominal sepsis, including multi-organ failure and bowel…
59-year-old woman died from intra-abdominal sepsis, multi-organ failure and bowel perforation following median hepatectomy for cholangiocarcinoma. Key clinical issues included: …
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