20y · Male·cardiac arrest due to complications of infective endocarditis against a backgrou…
Maluovailoa Tafau, a 20-year-old man in custody, died from cardiac arrest due to infective endocarditis complicated by rheumatic heart disease. He had submitted two patient self-referral forms (September 2016 and Februar…
0y · Male·cardiac arrhythmia associated with surgically corrected congenital heart disease
Edward Thomas Collins was a 3-month-old neonate with surgically corrected congenital heart disease (Total Anomalous Pulmonary Venous Drainage) who died on 14 January 2007 from cardiac arrhythmia. On 13 January 2007, he p…
59y · Male·disseminated carcinoma due to right lung carcinoma
Rex Harold, a 59-year-old Aboriginal man with schizophrenia, alcohol-induced brain injury, chronic obstructive airways disease, and diabetes, died in custody from disseminated small cell lung carcinoma. He was transferre…
17y · Male·stroke (left middle cerebral artery infarction) following motorbike collision du…
…ssection on initial CT scans (27 May 2021). Although appropriate angiographic imaging was ordered by the emergency physician, the radiologist failed to identify a subtle occlusion at the terminal carotid vessel on over …
35y · Male·Active rheumatic pancarditis complicated by pulmonary arterial hypertension, pne…
A 35-year-old Aboriginal man died from rheumatic pancarditis complicated by pulmonary hypertension, pneumonia and unspecified connective tissue disease. He had presented repeatedly to Katherine Hospital with symptoms sug…
32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome
Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included…
41y · Female·Intracerebral haemorrhage secondary to Posterior Reversible Encephalopathy Syndr…
Kerri Gunn, a 41-year-old woman five days post-caesarean delivery, presented to emergency with frontal headache, elevated blood pressure, proteinuria, abnormal liver function and lower limb oede…
57y · Male·brainstem and cerebellar infarction due to vertebrobasilar artery thrombosis
A 57-year-old man with multiple cardiovascular risk factors presented to an ED with vertigo, blurred vision, and 'not feeling right' caused by an evolving posterior circulation stroke. A junior doctor discharged him afte…
47y · Male·Pulmonary thrombo-embolism secondary to deep vein thrombosis in setting of morbi…
A 47-year-old man with morbid obesity presented with respiratory failure, productive cough, and calf swelling. His GP appropriately suspected both pneumonia and pulmonary embolism (PE), requesting urgent CTPA. At Townsvi…
68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…
Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mi…
46y · Female·Dilated cardiomyopathy (acute complication with sudden cardiac arrhythmia)
…-clinical carers; (2) the hospital failed to provide adequate carer education about diabetes management, emergency protocols, and when to seek help; (3) multiple presentations were missed opportunities for holistic asse…
81y · Female·Cardiac tamponade secondary to dissection of ascending aorta
An 81-year-old woman with hypertension and hypercholesterolaemia presented to the ED with sudden-onset central chest pain radiating to the jaw. Despite appropriate initial assessment and ruling out acute coronary syndrom…
74y · Male·Aspiration of gastric contents due to paralytic ileus following Whipple surgery …
William Searle, a 74-year-old prisoner, died from aspiration of gastric contents following a Whipple procedure for recurrent ampullary adenoma. The clinical lessons involve recognition of gastroparesis risk in high-risk …
60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…
James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…
83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)
An 83-year-old male prisoner died from complications of a ruptured abdominal aortic aneurysm (AAA) after a 5-month delay in diagnostic confirmation and treatment. An incidental finding of an 8.7 cm AAA was identified on …
64y · Female·Bilateral pulmonary embolism with left middle cerebral artery/posterior cerebral…
Marlene Kenny, 64, presented to Orbost Hospital on 8 January 2007 with chest tightness, breathing difficulties and low oxygen saturation (83-86%). A doctor diagnosed panic attack and discharged her without investigation.…
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