Female·haemopericardium due to aortic dissection (all three cases)
…lizabeth Hospital, South Australia. Beverley Coats (73) presented three times in July 2016 with back pain, nausea and vomiting; her known aortic dilatation was not documented in electronic records. Her death was not prev…
79y · Female·Dilated cardiomyopathy with decompensated heart failure not appropriately treate…
A 79-year-old woman with severe COPD and heart failure presented with two weeks of nausea and vomiting. She was diagnosed with left ventricular failure (EF 33%) on day 1 of admission. Two cardiolo…
18y · Male·complications of acute on chronic subdural haemorrhage (operated) in the setting…
…February 2019. He had suffered a head injury during sparring on 25 October 2018, presenting with headache, nausea and dizziness. Dr H. reviewed him on 31 October with ongoing symptoms but did not order a CT scan, which t…
57y · Female·Multi-organ failure due to drug-induced liver injury caused by sodium valproate …
…is in November 2019. She developed acute hepatitis approximately 5 months later, presenting with jaundice, nausea, and dark urine. Critical failures in clinical management included: (1) failure to cease sodium valproate …
68y · Female·Sepsis (Enterobacter cloacae) due to peritonitis as a consequence of leaking per…
… tube inserted on 27 February 2018. She presented to a rural hospital 5.5 hours post-discharge with fever, nausea, vomiting and abdominal pain. Critical failures included: failure to recognise sepsis despite elevated lac…
37y · Male·Complications due to atherosclerotic heart disease and dyslipidaemia
…called until 26 September. On 26 September at the clinic, he presented with severe hypotension (80/40) and nausea but was not recognised as having acute coronary syndrome; only partial observations were taken; he deterio…
43y · Male·Multi-organ failure with coagulopathy secondary to acute exacerbation of chronic…
…vailability of specialist equipment. Over Saturday, he deteriorated with worsening headache, vomiting, and nausea—classic signs of increased intracranial pressure. The neurosurgeon rescheduled surgery for Sunday morning …
53y · Male·fentanyl and oxycodone toxicity
Stephen Robert Atkins, 53, died from fentanyl and oxycodone toxicity after admission to Flinders Medical Centre for investigation of Horner's syndrome and radiculopathy. Over three days, escalating opioid doses were pres…
37y · Female·complications of withdrawal from chronic opiate use and Wilkie Syndrome in the s…
Veronica Nelson, a 37-year-old Aboriginal woman with opioid dependence, was arrested on minor theft charges, remanded in custody following a bail hearing, and held at Dame Phyllis Frost Centre (DPFC) women's prison. She …
41y · Female·complications of intracerebral haemorrhage due to ruptured aneurysm
Dannielle Stacey Lowe, a 41-year-old Aboriginal woman, died in custody at Wandoo Rehabilitation Prison from complications of intracerebral haemorrhage due to a ruptured cerebral aneurysm. Critical missed opportunities in…
36y · Male·perforated duodenal ulcer
…annabinoid Hyperemesis Syndrome (CHS) based on cannabis use that morning, despite the patient reporting no nausea or vomiting—cardinal features of CHS. No imaging was ordered. The misdiagnosis governed all subsequent tre…
41y · Male·Cerebral hypoxia and bronchopneumonia; contributing factors: toxic megacolon, ce…
David Orton, a 41-year-old man with cerebral palsy, intellectual disability, and severe kyphoscoliosis, died from cerebral hypoxia and bronchopneumonia complicated by toxic megacolon and Salmonella infection. Over 18 mon…
30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…
…ne. Following injection on 22 November 2021, she experienced symptoms consistent with opioid intoxication (nausea, vomiting, drowsiness). While asleep that night, she likely experienced respiratory depression from the co…
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