0y · Male·Complications of birth-related traumatic head injury
Tasman Murray Tribe, a neonate born at 36 weeks gestation, died at 7 days of age from complications of birth-related traumatic head injury. Labour was prolonged in the second stage; instrumental delivery was attempted bu…
43y · Female·Haemorrhage Associated with Penetrations of the Aorta
Margaret Brooks, a 43-year-old woman, died from haemorrhage associated with aortic penetrations during laparoscopic gastric band insertion at Kaleeya Hospital on 8 September 1999. The operation was undertaken for weight …
0y · Female·Perinatal asphyxia
Baby XY, a 41-week-old newborn, died from perinatal asphyxia six hours after birth at Sunshine Hospital. The primary clinical lesson involves diagnostic failure: the mother was not diagnosed with gestational diabetes dur…
68y · Male·Complications following myocardial infarction and its treatment in a man with mu…
Salvatore Otranto, a 68-year-old prisoner with multiple severe comorbidities including ischaemic heart disease, diabetes, COPD, and chronic kidney disease, died from complications of myocardial infarction and its treatme…
53y · Female·Heatstroke
Thi Qui Tran, a 53-year-old woman with schizophrenia on antipsychotic medications (zuclopenthixol and olanzapine), died of heatstroke on 9 February 2018 after collapsing on a street during extended unescorted leave from …
2y · Male·Severe hypoxic ischaemic encephalopathy (grade 3)
A term two-day-old baby died of severe hypoxic-ischaemic encephalopathy (grade 3) following a home birth on a farm 25km from hospital. The birth was complicated by shoulder dystocia and profound asphyxia. Although expert…
66y · Male·Multi-system failure and ischaemic gut after left nephrectomy complicated by mas…
A 66-year-old man died from multi-system failure and ischaemic bowel following laparoscopic left nephrectomy complicated by massive haemorrhage and vascular injury. During surgery for renal carcinoma, the surgeon attempt…
16y · Male·Heat related illness in an individual with enterovirus D68 infection
Alexander Li, a 16-year-old with underlying enterovirus D68 infection, died of heat-related illness during a school bushwalking expedition in remote South Australia in extremely hot conditions (temperatures reaching 39.1…
33y · Male·Haemoperitoneum secondary to lacerated spleen as a result of peritoneal ascitic …
A 33-year-old man with severe alcoholic liver disease (Child-Pugh C) and poor prognosis died from haemoperitoneum following splenic laceration during a diagnostic ascitic tap procedure. Two junior doctors (HMOs/Basic Phy…
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…
36y · Male·Cerebrovascular accident (stroke) - massive intracranial haemorrhage
An Aboriginal man with chronic alcoholism and cirrhosis died from a massive stroke (cerebrovascular accident) while in prison custody. He presented with non-specific symptoms including vomiting on 9 March 2005 and was pl…
Female·Betty: cardiac arrhythmia complicating heart failure due to consequences of past…
This inquest examined three deaths of young Aboriginal women from Doomadgee (ages 18, 37, and 17) from rheumatic heart disease (RHD) complications between September 2019 and September 2020. All three deaths were preventa…
75y · Male·Right haemothorax complicating intercostal catheter insertion for the treatment …
Giuseppe Costa, 75, died from right haemothorax following intercostal catheter insertion for pleural effusion drainage. Critical failures in clinical management included: inadequate documentation of pleural fluid drainag…
6y · Male·Global cerebral ischaemia secondary to perinatal asphyxia
HC was a neonate who died at 6 days old from global cerebral ischaemia secondary to perinatal asphyxia. He was born following an emergency caesarean section for obstructed labour and fetal distress. Key clinical lessons …
18y · Male·Hypoglycaemic hypoxic-ischaemic encephalopathy, due to massive liver necrosis, d…
An 18-year-old remand prisoner died from acute liver failure secondary to Hepatitis B and C infection. He presented with fever and malaise on 15 February but was assessed only for boils and not thoroughly evaluated. Clin…
11y · Male·Sepsis
An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…
45y · Female·Multisystem organ failure secondary to acute liver failure associated with parac…
Elsa Harrington, a 45-year-old woman, died from acute liver failure secondary to paracetamol toxicity in November 2002. She was admitted post-hysterectomy with bowel obstruction and underwent adhesion surgery. Following …
2y · Male·Perinatal asphyxia leading to cerebral anoxia and subsequent multi-organ failure
Sebastian Hewitt, born at 36 weeks gestation following maternal ante-partum haemorrhage and abnormal CTG traces, died from perinatal asphyxia leading to cerebral anoxia and multi-organ failure at 3 days old. Critical cli…
33y · Female·multiple organ failure complicating sepsis in a woman with cirrhosis of the live…
Amy Tinker, a 33-year-old Aboriginal woman with unrecognised cirrhosis from chronic alcohol abuse, died from sepsis-related multi-organ failure while imprisoned. She had been admitted to Royal Perth Hospital in 2004 with…
78y · Female·multi-organ failure due to haemorrhage into the abdomen, pelvis and retroperiton…
78-year-old Jehovah's Witness died from multi-organ failure secondary to intra-abdominal and retroperitoneal haemorrhage following extensive anterior and posterior lumbar spinal fusion surgery. The patient had multiple c…
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