61 results
77y · Male·Complications of reaction to an iron infusion in a man with ischaemic heart dise…
A 77-year-old man with iron deficiency anaemia and underlying ischaemic heart disease died from anaphylaxis following iron polymaltose infusion. Critical clinical lessons: (1) IV iron should only be administered after or…
75y · Female·large volume aspiration following right hemicolectomy for adenocarcinoma of the …
A 75-year-old woman with a 20-month history of iron deficiency anaemia was not investigated for its cause by her general practitioner despite clear clinical signs of deterioration. The coroner found this fell 'grossly sh…
39y · Female·Hypoxic brain injury secondary to multiple hypovolaemic cardiac arrests from cat…
Linda Parker, aged 39, died from hypoxic brain injury following catastrophic postpartum haemorrhage from placenta increta during caesarean delivery. Critical lessons: (1) Placenta increta risk was not detected prenatally…
68y · Female·acute gastrointestinal haemorrhage secondary to bilateral dental extraction
A 68-year-old woman on long-term warfarin therapy for a prosthetic aortic valve died from acute gastrointestinal haemorrhage following dental extraction. The dentist failed to obtain an INR test within 24 hours of the pr…
81y · Male·Intracerebral haemorrhage in the setting of heparinisation for subclavian artery…
81-year-old Alan Webster with atrial fibrillation on long-term Warfarin underwent colonoscopy in August 2011. His anticoagulation was interrupted and bridging Clexane prescribed. Post-operatively, critically sub-optimal …
17y · Male·Multi-organ failure with terminal fungal sepsis (Aspergillus) on a background of…
Ben Witham, a 17-year-old with acute lymphoblastic leukaemia, died from multi-organ failure with terminal fungal sepsis. The critical issue identified was a substantial delay in investigating acute severe abdominal pain …
43y · Female·Acute thrombosis of a prosthetic mitral valve
A 43-year-old woman with prosthetic mitral and aortic valves due to rheumatic heart disease died from acute thrombosis of her prosthetic mitral valve following cessation and recommencement of warfarin for IVF treatment. …
63y · Female·Intra-cerebral bleed secondary to thrombocytopenia in a person with prolymphocyt…
Josephine Troy, 63, died on 14 February 2006 at Bunbury Regional Hospital from an intracerebral bleed secondary to thrombocytopenia (platelet count of 1) arising from prolymphocytic leukaemia. She had been in remission f…
38y · Female·Pulmonary Thromboembolism
Kellie Anne Keogh, 38, died from pulmonary thromboembolism on 10 November 2008 after complex pancreatic surgery. She had nephrotic syndrome with decreased anti-thrombin III levels, initially presenting with suspected DVT…
81y · Male·Retropubic and retroperitoneal haemorrhage complicating pelvic fractures with co…
An 81-year-old man died from retropubic and retroperitoneal haemorrhage complicating pelvic fractures sustained in a fall at church. He was on warfarin for atrial fibrillation with an excessive INR of 4.6 at the time of …
81y · Female·hypovolaemic shock following bleeding from the site of a femoral angiogram
Olga Krivitch, 81-year-old woman, died from hypovolaemic shock caused by bleeding from her femoral angiogram puncture site. She was admitted for ischaemic leg and underwent unsuccessful thrombolytic therapy. Subsequently…
65y · Male·acute right subdural haematoma
Sidney Brunt, aged 65, died from an acute right subdural haematoma caused by excessive, unmonitored anticoagulation with warfarin. His general practitioner, Dr A., prescribed warfarin for atrial fibrillation but failed t…
14y · Female·blunt force head injury
A 14-year-old Aboriginal girl with newly diagnosed idiopathic thrombocytopenic purpura (ITP) and critically low platelet count (5,000/mm³) absconded from Alice Springs Hospital on 27 January 2006. Hospital staff failed t…
45y · Female·Extensive retroperitoneal haemorrhage following bone marrow biopsy procedure wit…
Susan Denise Evans, a 45-year-old woman with complex medical history including neurofibromatosis type 1, essential thrombocytosis, prior cancers, and recent cerebral infarcts on warfarin, underwent bone marrow biopsy at …
77y · Female·haemorrhagic diathesis due to warfarin toxicity
Ruby Mabel Edwards, 77, died from haemorrhagic diathesis due to warfarin toxicity after 84 days in a rural hospital. She had a prosthetic aortic valve requiring anticoagulation. INR monitoring was inadequate: no tests fo…
35y · Male·pulmonary thromboembolism due to left deep calf vein thrombosis complicating lef…
John Matthew Murray, aged 35, died of pulmonary thromboembolism complicating pelvic and leg fractures sustained in a motorcycle accident. He was admitted to Royal Adelaide Hospital and underwent extensive orthopaedic sur…
35y · Male·Disseminated Lymphoblastic Lymphoma
A 35-year-old Aboriginal man died from disseminated lymphoblastic lymphoma while in prison custody. He presented with progressive symptoms including oedema, shortness of breath, and difficulty walking. Dr J. appropriatel…
90y · Female·incompatible blood transfusion resulting in haemolysis and multi-organ failure c…
A 90-year-old woman with acute myocardial infarction and cardiogenic shock died after receiving an incompatible blood transfusion (A- instead of O+), which caused haemolysis and multi-organ failure. The registered nurse …
71y · Female·massive acute haemolysis leading to severe anaemia and multi-system failure as a…
Ruth Stoll, 71, died from massive acute haemolysis and multi-system failure after receiving incompatible blood transfusions during aortic aneurysm repair. Pre-operative blood samples from Stoll and another patient (Koven…
59y · Female·multiple cerebral infarction due to infective endocarditis
A 59-year-old woman with known mitral valve disease presented to the Emergency Department on 19 October 2000 with widespread body pain, severe back pain, and fever. She was undoubtedly suffering from staphylococcus aureu…
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