94y · Male·Multi-system organ failure, peritonitis, acute gangrenous cholecystitis with cho…
…morbidities (ischaemic heart disease, diabetes, dementia), died of multi-system organ failure secondary to sepsis from acute gangrenous cholecystitis. An advanced care plan documented his wish for comfort-focused care on…
34y · Male·sepsis due to extensive small bowel infarct caused by bowel incarceration within…
Jason Keith Harrison, aged 34, died from sepsis due to extensive small bowel infarction caused by bowel incarceration within a congenital mesenteric herni…
75y · Female·Complications including acute pancreatitis and refractory intra-abdominal sepsis…
Lee Milcherdy, 75, died from complications including acute pancreatitis and refractory intra-abdominal sepsis following an unnecessary ERCP procedure. An MRCP scan on 12 October 2018 showed no gallstone, making the p…
34y · Male·Staphylococcus aureus sepsis and endocarditis
…tibiotics via GP rather than hospital readmission. Mr Hosking deteriorated at home and died by 3.30pm from sepsis and endocarditis. Key failures: premature discharge without senior review, no system for communicating cri…
65y · Male·escherichia coli urosepsis
Dr G., a 65-year-old psychologist, died from escherichia coli urosepsis following pyeloscopic kidney stone extraction. Post-operative fever developed within 2 hours of surgery. B…
3y · Male·Hypoxic brain injury secondary to cardiorespiratory arrest, possibly secondary t…
Master T, aged 3 years, died from hypoxic brain injury secondary to cardiorespiratory arrest, likely due to aspiration pneumonitis. He had severe congenital abnormalities including holoprosencephaly with VP shunt, anal a…
3y · Male·Influenza A infection (Type H3N2)
Aidan Mara, a 3-year-old boy with influenza A pneumonia and hyponatraemia, collapsed and died from cardiovascular failure on hospital day 3. Critical clinical lessons include: (1) distinguishing SIADH from dehydration ea…
23y · Female·Necrotising retroperitoneal fasciitis due to acute perforated gangrenous appendi…
…tus. She re-presented 2 May with perforated appendicitis causing necrotising retroperitoneal fasciitis and sepsis, dying 7 May 2015 despite surgical intervention. Key clinical lessons: presumption of capacity may not app…
69y · Female·Septic shock due to biliary peritonitis as a consequence of laparoscopic cholecy…
…ay 1 despite consultant's undocumented concerns; (2) failure to initiate antibiotics at ward round despite sepsis indicators; (3) delayed surgical response despite documented critical illness; (4) poor communication betw…
75y · Female·organ failure due to sepsis, likely from infected pressure sores, in the context…
Maria Carmel Niceforo, a 75-year-old woman with poorly controlled diabetes and ischaemic heart disease, died from septic shock secondary to extensive infected sacral pressure wounds. She received home care through KinCar…
85y · Female·Staphylococcus bacteremia complicating multiple injuries sustained in a motor ve…
An 85-year-old woman sustained multiple serious injuries (bilateral rib and pelvic fractures, thoracic spine fractures) in a motor vehicle collision on 20 June 2018. She was treated with ICU admission, induced coma, and …
77y · Female·Haemoperitoneum following cholecystectomy
…morrhage), failure to check coagulation status until 7:45 pm despite therapeutic anticoagulation, lack of urinary catheter insertion until 8:00 pm, delayed antibiotic administration, and poor inter-team communication an…
64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …
Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic l…
38y · Female·Streptococcus Group A Septicaemia (Post Partum-Puerperal Sepsis)
…vie, a 38-year-old woman, died on 6 April 2006 from untreated Group A Streptococcal septicaemia (puerperal sepsis) following childbirth at Osborne Park Hospital. She developed fever (38°C) at 3am on 5 April, only three h…
20y · Male·anoxic brain injury following cardio-respiratory arrest caused by hypoxia result…
A 20-year-old male died from anoxic brain injury following cardiac arrest caused by hypoxia resulting from tracheostomy tube occlusion. After motor vehicle trauma, he underwent surgery and was eventually transferred to a…
34y · Male·multi-organ failure with right-sided tension pneumothorax
…iagnostic information (imaging plus clinical findings) are essential to avoid missed diagnosis of evolving sepsis.
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…
21y · Male·Sepsis caused by Leptospirosis (Graeme Gulliver); Group A streptococcal meningit…
Three young patients died from severe bacterial infections at rural Queensland hospitals (Mossman and Atherton). All three received delayed diagnoses and treatment. The first patient (21-year-old with leptospirosis) pres…
66y · Male·multiple organ failure associated with the combined effects of complications of …
…re toxicity with vomiting, diarrhoea and mouth ulcers. When he returned with symptoms, Dr H. misdiagnosed urinary tract infection and failed to investigate the methotrexate. He was later hospitalized with severe immunos…
42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…
…ar-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ridge Multi-Purpose …
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