166 results
76y · Male·pulmonary thromboembolism in the setting of deep vein thrombosis
A 76-year-old man with a history of unprovoked DVT/PE on lifelong warfarin was admitted with COVID-19 and developed a bleeding duodenal ulcer requiring endoscopic treatment. Warfarin was ceased to prevent further bleedin…
26y · Female·meningococcal infection (Neisseria meningitidis W strain) causing septicaemia
Ashleigh Rebecca Hunter, a previously healthy 26-year-old, died from meningococcal septicaemia (W strain) within 3 hours of arriving at Royal Perth Hospital. She presented with severe generalised pain (10/10), tachycardi…
75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis
A 75-year-old woman with chronic pain and previous staphylococcal infections presented to Glen Innes District Hospital with a swollen, warm right knee 10 days after a corticosteroid injection. Junior doctor Dr M. appropr…
12y · Female·Hypoxic ischaemic encephalopathy complicating an aortic root abscess (operated) …
A 12-year-old Aboriginal girl with a bicuspid aortic valve and autism spectrum disorder presented with a week of fever and non-specific symptoms (cough, vomiting, abdominal pain, chest pain) to a rural hospital. Despite …
Female·Betty: cardiac arrhythmia complicating heart failure due to consequences of past…
This inquest examined three deaths of young Aboriginal women from Doomadgee (ages 18, 37, and 17) from rheumatic heart disease (RHD) complications between September 2019 and September 2020. All three deaths were preventa…
56y · Male·Complications of clostridium difficile and malnutrition in the setting of cerebr…
Mr C was a 56-year-old man with cerebral palsy and acquired brain injury who died from complications of Clostridioides difficile infection and malnutrition. He was admitted to hospital on 21 January 2022 with diarrhoea, …
51y · Male·COVID-19 pneumonia
Suong Van Nguyen, a 51-year-old worker at a chicken processing plant, died from COVID-19 pneumonia during home isolation in August 2020. He tested positive on 31 July, reported shortness of breath on 2 August, then becam…
84y · Male·Respiratory failure complicating hospital acquired pneumonia following surgical …
An 84-year-old man died from respiratory failure due to hospital-acquired pneumonia following surgery for recurrent mandibular squamous cell carcinoma. Key clinical lessons: (1) Advanced Care Plans (ACPs) must be activel…
7y · Female·multiorgan failure due to fulminant sepsis (Streptococcus pyogenes)
7-year-old Aishwarya Aswath Chavittupara died from multiorgan failure due to fulminant sepsis (Streptococcus pyogenes) after approximately 90 minutes in Perth Children's Hospital emergency department. She presented with …
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
Maarouf El-Cheikh, a 57-year-old man with splenectomy history, presented to Calvary Hospital ED with sepsis on 21 March 2016 and died 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadeq…
3y · Male·Disseminated Staphylococcus aureus infection
A 3-year-old Aboriginal boy died from disseminated Staphylococcus aureus infection with sepsis. He presented to a remote clinic on 10 April with fever and dizziness, then returned on 13 April with irregular fever, lethar…
59y · Male·complications of viral liver cirrhosis with hepatocellular carcinoma
Mervyn Morgan, aged 59, died from complications of hepatocellular carcinoma arising from cirrhosis while in prison custody. Critical failures included: delayed monitoring of known liver cirrhosis (no ultrasound despite M…
89y · Male·septicaemia due to infected groin wound, femoropopliteal bypass in a man with mu…
An 89-year-old man with multiple comorbidities (diabetes, peripheral vascular disease, heart failure) developed a groin wound infection following femoropopliteal bypass surgery while residing in aged care. The wound dete…
20y · Male·cardiac arrest due to complications of infective endocarditis against a backgrou…
Maluovailoa Tafau, a 20-year-old man in custody, died from cardiac arrest due to infective endocarditis complicated by rheumatic heart disease. He had submitted two patient self-referral forms (September 2016 and Februar…
66y · Male·sepsis following bacteraemia caused by transurethral catheter insertion
A 66-year-old man with severe dementia and multiple comorbidities died from sepsis following bacteraemia after a routine indwelling urinary catheter change at a nursing home. The catheter insertion was traumatic, resulti…
73y · Male·Infectious Exacerbation of Chronic Obstructive Airways Disease with the Contribu…
Mr H, a 73-year-old man with chronic obstructive airways disease and Lewy body dementia, was admitted to hospital on 6 January 2021 following a psychiatric incident and was found to have pneumonia and severe infection. H…
63y · Female·Escherichia coli septicaemia in a lady with multiple comorbidities
Helen Welsh, 63, died from E. coli septicaemia with multiple comorbidities. She presented with respiratory symptoms and underwent bronchoscopy. On discharge day, she deteriorated with fever, altered consciousness, and hy…
80y · Male·Multiple injuries post fall from a roof
An 80-year-old man died from multiple injuries sustained in a fall from a roof while cleaning gutters at home. He fell approximately 2 metres from a ladder, sustaining rib, pelvis, and spine fractures, plus vertebral art…
85y · Male·Incised wounds to the wrist
An 85-year-old man with myelodysplasia and severe hip pain from an ischiorectal abscess died from incised wrist wounds sustained in a nursing home while in palliative care. He had expressed wishes to die, discussed eutha…
47y · Female·Traumatic closed head injury likely sustained in a fall from standing
TS, a 47-year-old woman with a 18-year history of anorexia nervosa, bulimia, and severe alcoholism, died from a traumatic closed head injury sustained in a fall from standing. At autopsy, blood alcohol concentration was …
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