5y · Female·Cerebral hypoxic and ischaemic injury in a setting of clinical birth asphyxia
…m (CTG) trace but was born in poor condition (Apgar 2/5/7), requiring respiratory support. Necropsy found cerebral hypoxic-ischaemic injury from clinical birth asphyxia, with the insult occurring 6-8 hours before deliver…
71y · Male·Organ failure in an elderly man receiving palliative medical care for renal fail…
Gheorghe Gruici, a 71-year-old life-sentenced prisoner, died of organ failure from chronic renal failure, infective endocarditis, and chest infection. Over 15 years in custody, he developed multiple comorbidities includi…
64y · Female·Bilateral pulmonary embolism with left middle cerebral artery/posterior cerebral…
…inical urgency, ineffective bed coordination, and adverse weather. She deteriorated, suffered myocardial infarction, and died from bilateral pulmonary embolism complicated by stroke. Key failures: initial hypoxia not inv…
37y · Male·Coronary artery thrombosis resulting from coronary atherosclerosis with contribu…
Marshall Yantarrnga, a 37-year-old Aboriginal man with significant cardiac history (prior mitral valve replacement in 1996), presented with chest and right-sided pain, fever, and was assessed by ambulance officers on 29 …
2y · Male·Tramadol toxicity in the setting of adenotonsillectomy in a child with Pierre Ro…
Dane Hortle, a 2-year-old with Pierre Robin Sequence and obstructive sleep apnoea, died from tramadol toxicity following adenotonsillectomy. He was discharged with a prescription for tramadol 25mg, which was dispensed as…
1y · Female·Sepsis (Group A Streptococcus)
…on. The child deteriorated acutely with petechial haemorrhages and shock, ultimately developing bilateral cerebral infarction despite intensive care. Key lessons include implementing paediatric early warning tools (CEWT)…
0y · Male·Head injury sustained in a difficult delivery including head impaction and caesa…
Baby Sidney died from severe hypoxic-ischaemic encephalopathy caused by head impaction during a difficult vaginal delivery attempt and subsequent caesarean section at 6 days old. The coroner found that medical care fell …
56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy
A 56-year-old woman presented to Knox Private Hospital with severe headache and eye symptoms on 16 June 2007. An ED physician diagnosed ischaemic stroke based on a subtle CT finding in the absence of focal neurological s…
61y · Male·Intracranial haemorrhage and myocardial infarct
A 61-year-old man with extensive cardiac disease collapsed at a supermarket, striking his head and losing consciousness for less than 10 seconds. Paramedics identified STEMI and administered heparin on advice from Austin…
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