445 results
<1y · Male·Hypoxic ischaemic encephalopathy due to an out of hospital cardiac arrest second…
A 10-month-old boy drowned in a backyard fishpond after a 27-minute period of inadequate supervision. He was found unresponsive by his aunt and underwent prolonged resuscitation, suffering severe hypoxic brain injury. De…
45y · Female·COVID pneumonia complicated by severe electrolyte abnormalities
A 45-year-old woman with cerebral palsy, Smith-Lemli-Opitz syndrome, and blindness died from COVID pneumonia complicated by severe electrolyte abnormalities. She was admitted three times over 3 weeks with progressive ele…
<1y · 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…
<1y · Male·Pneumonia (early-onset, caused by Group B Streptococcus)
Baby XR died at one day old from early-onset pneumonia caused by Group B Streptococcus (GBS) acquired during vaginal delivery. The mother had known GBS colonisation and received intrapartum prophylactic antibiotics as pe…
68y · Female·haemopericardium resulting from perforation of the pericardial sac during laparo…
Mrs Christine Flynn, aged 68, died from haemopericardium and pericardial tamponade following laparoscopic hiatus hernia repair. A 2mm perforation of the pericardial sac occurred during surgery, likely from mesh tacks pla…
40y · Male·Acute hepatic and renal failure in the setting of postoperative haemorrhage foll…
A 40-year-old man with obesity, COPD, diabetes and hypertension died from acute hepatic and renal failure following postoperative haemorrhage after left radical nephrectomy for a 10cm renal cell carcinoma. The surgeon ap…
73y · Female·Multi organ failure due to adhesions related bowel perforation (surgically treat…
Sharyn Kaine, a 73-year-old woman, died from multi-organ failure due to adhesions-related bowel perforation and paracetamol-induced liver failure. She was prescribed intravenous paracetamol 1g four times daily post-opera…
62y · Female·Complications arising from elective laparoscopic Hartmann's procedure for recurr…
Christine Flanagan, a 62-year-old woman with severe disabilities and gastroparesis, died from complications following an elective laparoscopic Hartmann's procedure for recurrent sigmoid volvulus and ileus. Post-operative…
51y · Female·Methemoglobinemia in the context of lignocaine use
Danielle Cadan, 51, died from methemoglobinemia following a tooth extraction under lignocaine anaesthetic at a regional health service. The lignocaine was administered in normal therapeutic dose but triggered this rare l…
16y · Male·transection of the liver and laceration of the inferior vena cava sustained in a…
A 16-year-old male died from transection of the liver and inferior vena cava laceration sustained in a quad bike accident. He was riding a single-rider ATV with a pillion passenger when he entered a left-hand corner too …
16y · Male·mid-gut volvulus and bowel obstruction, leading to ischaemic bowel and related c…
Finlay Browne, a 16-year-old with Down syndrome, presented to Bathurst Base Hospital on 30 September 2016 with acute abdominal pain and vomiting. Despite clear clinical signs—including a lactate of 7.2 mmol/L (grossly ab…
<1y · Male·multifactorial with severe hypoxia/hypotension which occurred in the background …
Everett Carleton died at birth following an emergency caesarean section complicated by unexpected placenta praevia and umbilical cord transection. The placenta was incorrectly reported as posterior on ultrasound, though …
17y · Male·stroke (left middle cerebral artery infarction) following motorbike collision du…
Kane Mathew Leary, 17, died from a stroke (left middle cerebral artery infarction) following a motorbike collision. The critical clinical lesson involves a missed diagnosis of left internal carotid artery dissection on i…
69y · Male·Septic arthritis of the knee
Frank Hall-Bentick, a 69-year-old man with severe muscular dystrophy and restrictive lung disease dependent on 24-hour BiPAP, presented to Austin Hospital with septic arthritis of the right knee and septic shock. A multi…
12y · Male·Injuries sustained in a quad bike incident (driver)
A 12-year-old boy died from injuries sustained in a quad bike accident on his family's rural property. He was riding unsupervised without parental permission when the bike collided with a drain bank, flipping and impalin…
70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia
70-year-old Sean Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner identified multiple significant failing…
68y · Female·mixed prescription drug toxicity (oxycodone, metoprolol, diazepam)
Ms Heraghty, a 68-year-old woman with multiple comorbidities including obesity (BMI 47.3), atrial fibrillation, COPD, and severe chronic pain, died from mixed prescription drug toxicity (oxycodone, metoprolol, diazepam) …
46y · Male·sepsis following haemorrhoidectomy
46-year-old Justin Mark Dobson died from sepsis following a routine haemorrhoidectomy on 17 July 2019. He was discharged to the ward overnight but deteriorated significantly from 11:00 am on 18 July, showing hypotension,…
59y · Female·Asphyxial aspiration with upper airways obstruction by vomitus
Ms Prenc, a 59-year-old woman with spina bifida, died from asphyxial aspiration with upper airway obstruction by vomitus while hospitalised for urosepsis. The critical clinical issue was a Goals of Care (GOC) document co…
54y · Male·Hypoxic/ischaemic brain damage caused by blood loss and airway obstruction due t…
A 54-year-old male was assaulted in a nightclub with a single punch causing orbital and facial fractures and posterior epistaxis. He presented to the Royal Hobart Hospital ED with active bleeding. Critical deficits in hi…
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