32y · Female·Mexiletine toxicity
… major depression and anxiety. In August 2007, she was admitted to St Vincent's Hospital with generalised weakness. The neurology team failed to notify her psychiatrist, Dr C., of her admission despite her known psychiat…
5y · Male·aspiration pneumonia with terminal palliative care, in a male child with complex…
A 5-year-old boy with severe congenital myopathy and arthrogryposis died from aspiration pneumonia following terminal palliative care. He had multiple complex medical needs including unsafe swallowing, recurrent respirat…
41y · Female·Left middle cerebral artery territory ischaemic stroke
…s having a possible medication overdose rather than acute stroke, despite later learning she had reported weakness on her right side and suspected stroke that morning. A CT brain was not ordered initially; it was perform…
0y · Male·Pneumonia in the setting of malnutrition
…iting and feeding difficulties. Parents delayed seeking medical help despite clear warning signs (pallor, weakness, poor feeding, irregular breathing) and did not call emergency services even after finding him unresponsi…
71y · Male·Complications following a right hepatic artery injury following an open cholecys…
A 71-year-old man with myelofibrosis and prior abdominal surgery died from complications of a right hepatic artery injury during open cholecystectomy for acute cholecystitis. The operative decision was reasonable and the…
93y · Male·Intracranial haemorrhage in the setting of over-warfarinisation
A 93-year-old man on warfarin for atrial fibrillation sustained a head strike in a fall at residential aged care. Initial assessment by ambulance was appropriate and he was not transferred. Over subsequent days, neurolog…
46y · Female·hemopericardium secondary to dissection of the thoracic aorta
…a, presented to the ED on 8 October 2008 with sudden-onset severe throat pain, bradycardia, and right arm weakness. She was discharged after 4 hours observation with a diagnosis of gastro-oesophageal reflux disease. She …
3y · Male·respiratory failure, with spinal muscular atrophy an antecedent cause
Tory Ganderton, a 3-year-old boy with spinal muscular atrophy (SMA) Type 1, died of respiratory failure during inter-hospital transfer. Admitted to Shoalhaven Hospital on 7 September 2014 with pneumonia and severe malnut…
41y · Female·Multiple injuries from assault
A 41-year-old woman with physical disability and stable mental health was killed by her adult son through severe blunt force trauma including extensive rib fractures causing flail chest, pneumohaemothorax, liver lacerati…
28y · Male·neck compression due to hanging
Mark Payne, 28, a remand prisoner at Yatala Labour Prison, hanged himself in his cell on 2 June 2011 using a canvas smock. He had made recent threats of self-harm and was placed under camera observation in G Division. Th…
47y · Male·pericardial tamponade secondary to ruptured dissecting thoracic aortic aneurysm …
…aortic aneurysm. He presented to Austin Hospital ED on 22 February 2008 with chest pain, diaphoresis, and weakness, but was misdiagnosed with gastroenteritis. Critical clinical information documenting his cardiac risk fa…
50y · Female·septicaemia
…2011 at her home in Bundaberg. Over 4-5 days prior to death, she developed progressive symptoms including weakness, incontinence, diarrhoea/vomiting, shaking and cold extremities—consistent with systemic infection. Her h…
33y · Female·Raised intracranial pressure secondary to thrombosis of the superior sagittal, t…
A 33-year-old woman presented with acute neurological symptoms (headaches, weakness, slurred speech, seizures) on 26 August 2000. Initial CT imaging showed focal haemorrhage with oedema; re…
48y · Female·Acute respiratory failure (cerebral hypoxia) in a woman dependent on non-invasiv…
Michelle Griffin, 48, with motor neurone disease, died from acute respiratory failure while dependent on non-invasive ventilation (NIV) at home. A carer, Julie Manessis, was caring for her when the humidifier tipped over…
31y · Male·Lymphocytic Myocarditis in association with Acute Pericarditis (viral origin, ae…
… (viral origin). He presented to Carnarvon Regional Hospital on 20 December with chest and shoulder pain, weakness, and lethargy following previous pneumonia in October. Initial investigations suggested infection but lac…
13y · Female·cerebral oedema and infarction secondary to extensive subdural empyema
…January 2004 and was initially seen at a GP and Noarlunga Health Service. When she returned with left leg weakness, she was appropriately transferred to Flinders Medical Centre where Dr T. performed an excellent clinical…
18y · Female·multi-organ failure due to combined effects of environmental exposure (hyperther…
…ng athletes unaware of the dangers. Warning signs of critical dehydration (inability to sweat, confusion, weakness) went unrecognised. No medical supervision occurred during her preparation. Clinicians should educate you…
82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis
…dities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was not placed on a pressure-relieving mattr…
73y · Female·Unknown due to decomposition
Mrs Chrupalo, a 73-year-old woman with physical disability, cognitive impairment and alcohol dependency, was discharged from Dubbo Base Hospital on 8 July 2015 against medical advice despite being bedbound and dependent …
78y · Female·Severe burns sustained while smoking
A 78-year-old woman with dementia and significant manual dexterity deficits suffered fatal burns while smoking unsupervised in an aged care facility. Despite documented cognitive impairment and physical limitations preve…
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