74 results
63y · Female·bile peritonitis as a complication from a laparoscopic cholecystectomy
A 63-year-old woman died from bile peritonitis following laparoscopic cholecystectomy. The surgeon's intraoperative management was appropriate with no identified injuries. However, critical clinical deterioration on post…
45y · Male·Hypoxic-ischaemic encephalopathy due to prolonged hypoxia
A 45-year-old man died from hypoxic-ischaemic encephalopathy following cardiopulmonary arrest 11 hours after elective wrist plate removal surgery. Multiple contributing factors were identified: undisclosed obstructive sl…
Unknown·Ms Choi: hypoxic brain damage due to drowning/immersion due to rafting accident;…
Two language students died following a white water rafting incident on the Tully River. A collision between rafts diverted one raft into a hazardous channel, causing it to strike Sieve Rock and flip. Both occupants becam…
34y · Male·Air embolism and severe haemorrhage due to perforation of the right subclavian v…
Darryl Smith, aged 34, died following emergency surgery for a fractured clavicle at Sunnybank Private Hospital. During the final drilling of the sixth screw hole, the surgeon's drill penetrated the underlying right subcl…
2y · Male·Group A Streptococcal toxic shock syndrome which probably originated in the thro…
Ryan Saunders, a 2-year-old boy, died from Group A Streptococcal toxic shock syndrome after a 72-hour presentation with fever, pain, and systemic illness. Initial GP care was appropriate given the presentation and diagno…
12y · Female·Raised intracranial pressure due to acute-on-chronic hydrocephalus in the contex…
Samantha Rose Spence, 12 years old, died two days after spinal fusion surgery for severe scoliosis. She had a pre-existing, asymptomatic Chiari type 1 malformation detected on pre-operative MRI of her spine. A paediatric…
68y · Female·Anaphylactoid reaction to intravenous CT scan contrast medium leading to cardior…
A 68-year-old woman with asthma presented to hospital with abdominal pain suggestive of biliary obstruction. A CT scan with intravenous contrast was ordered to clarify the diagnosis before potential surgical transfer. Sh…
75y · Female·Septicaemia as a result of lobar pneumonia; congestive heart failure also presen…
A 75-year-old woman died from septicaemia following a percutaneous tracheostomy procedure performed by a locum consultant on a Sunday. The procedure deviated significantly from the established ICU protocol: it was perfor…
82y · Female·Complications from hypoglycaemic brain damage and cerebral vascular accident
Margaret Allan Johnston, 82-year-old admitted for UTI and confusion, was found comatose on 4 September 2006 with severe hypoglycaemia (glucose 0.8 mmol/L) despite being non-diabetic. Blood tests revealed high insulin and…
Female·meconium aspiration
Talisha Hildebrandt was stillborn at Ayr Hospital on 7 January 2007 due to meconium aspiration. The pregnancy was low-risk and managed appropriately. A CTG monitor showed concerning fetal heart rate changes, prompting ur…
0y · Male·Intrapartum head injuries secondary to brow presentation and obstructed labour
Benjamin Glasgow died shortly after emergency caesarean delivery at 12:30 pm on 19 October 2006 for brow presentation, an obstructed labour. Autopsy revealed unprecedented multiple skull fractures and severe brain injury…
83y · Female·Haemorrhage due to mitral valve disease (surgically repaired); specifically haem…
An 83-year-old woman died from haemorrhage following mitral and tricuspid valve repair surgery. During intra-operative testing of the repaired mitral valve using Blake's tubing (soft rubber tubing with a bevelled end) at…
67y · Male·Complicated endotracheal tube insertion due to or as a consequence of recent clo…
Oliver Steven McVey, a premature twin born at 31 weeks gestation weighing 1036g, died from complications of endotracheal tube re-insertion at 67 days of age. Following successful surgical ligation of a patent ductus arte…
Female·death by drug toxicity
Melanie Boyd, a teenager, died from drug toxicity at an unsupervised youth party where she consumed illicit drugs, prescription medications, and excessive alcohol. The inquest revealed critical failures in recognising he…
26y · Male·Air embolism due to ruptured spleen (surgery) due to motorcycle accident
John Mathers, 26, died from air embolism during emergency surgery following severe motorcycle trauma. A sedan turned across his path; despite heavy braking, he collided and suffered extensive injuries including ruptured …
62y · Female·Haemorrhage caused by abdominoperineal excision of the rectum
A 62-year-old woman died of uncontrollable haemorrhage following an abdominoperineal excision of the rectum (APER) at a remote hospital. The coroner found the operation itself was inappropriate: performed for undiagnosed…
10y · Female·Head injuries due to fall from a bunk bed
Elise Neville, aged 10, fell from a non-compliant bunk bed and sustained a head injury. At her first ED presentation to Caloundra Hospital at 3:25am, Dr D.—a junior house officer 19 hours into a 24-hour shift—failed to p…
66y · Male·Coronary atherosclerosis
Frank Maurice Whittington, aged 66, died from coronary atherosclerosis on 24 February 2004, shortly after day surgery to replace a catheter on his intrathecal morphine pump. Dr Rossato and RN Couper administered a 0.26ml…
49y · Female·Intra-abdominal haemorrhage, septic and haemorrhagic shock as a result of a lapa…
Deborah Burgen died from intra-abdominal haemorrhage complicated by septic shock following delayed emergency surgery for bowel obstruction. She attended the emergency department six times over eleven days with identical …
Female·Coronary atherosclerosis with ischaemic small bowel and Alzheimer's disease
Marjorie Joyce Tanner, an elderly woman with Alzheimer's disease, presented to Maryborough Hospital with a three-day history of abdominal pain, distension, and vomiting. Initially diagnosed with simple constipation and t…
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