0y · Unknown·unascertained
A 10-day-old neonate born at 36 weeks gestation presented to hospital with signs of sepsis including hypothermia, lethargy, poor feeding, and jaundice. Critical failures in recognition and triage occurred: the infant was…
4y · Female·aspiration of vomitus and its treatment due to rheumatic carditis against a back…
A 4-year-old Aboriginal girl from Doomadgee died on 23 July 2009 from aspiration of vomitus complicating rheumatic carditis with concurrent viral respiratory tract infection. She presented with fever and cough on 19, 21,…
34y · Male·multi-organ failure with right-sided tension pneumothorax
A 34-year-old man with a ruptured spleen and fractured ribs presented to the Emergency Department on multiple occasions with abdominal and chest pain. He was discharged on 28 February, 5 March and 6 March without admissi…
15y · Male·Cardiorespiratory arrest of unknown aetiology complicating hypoxic ischaemic enc…
Max McKenzie, a 15-year-old with asthma and food allergies, died from cardiorespiratory arrest complicating hypoxic ischaemic encephalopathy after severe refractory anaphylaxis. After eating apple crumble containing nuts…
45y · Male·Recurrence of ventricular fibrillation due to Brugada Syndrome
Craig Williams, 45, suffered an out-of-hospital cardiac arrest in 2015 due to presumptive Brugada Syndrome. He survived with severe hypoxic brain injury and spent 10 months rehabilitating at Cairns Hospital, where he was…
38y · Female·peritonitis with septic shock secondary to perforation of the gastrointestinal t…
A 38-year-old woman in persistent vegetative state following anoxic encephalopathy from anaphylaxis during surgery died from peritonitis caused by perforation at the gastrostomy stoma site. The perforation likely occurre…
2y · Male·Myocarditis secondary to Kawasaki Disease
Christopher Tao, aged 2 years 9 months, presented to Princess Margaret Hospital ED with a 5-day fever, cervical lymphadenopathy, rash, conjunctivitis, and other features diagnostic of Kawasaki Disease (KD) on 7 September…
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: surgical delays of 20 days between stent in…
25y · Female·Airway obstruction complicating laryngeal dilation for the treatment of subglott…
Ms Sobb, a 25-year-old woman with spondylo-epi-metaphyseal dysplasia causing severe airway abnormalities and subglottic stenosis, died from airway obstruction following laryngeal dilation. She was admitted to ICU with as…
31y · Female·cerebral anoxia following attempted intubation pre-surgery in a woman with torti…
Rachael Anne Rasmussen, a 31-year-old mother of three with severe neck deformities (torticollis, dysmorphia, short rigid neck), died on 17 June 2003 from cerebral anoxia following attempted intubation at Joondalup Health…
40y · Male·septic complications from injuries received from multiple dog bites sustained on…
Colin Amatto, a 40-year-old Yuin man, died from septic complications following a devastating dog attack with over 80 bite wounds. Critical clinical lesson: the same dog (Boof, a Staffordshire Bull Terrier) had attacked a…
39y · Male·Hypoxic brain injury due to respiratory obstruction following surgery for dental…
Richard Christopher Jankowski, a 39-year-old man, died from hypoxic brain injury due to respiratory obstruction following emergency surgery for a dental abscess with cellulitis. After initial treatment with antibiotics, …
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