1,489 results
89y · Male·Complications of chest injuries sustained in a motor vehicle incident (driver)
An 89-year-old man with advanced bilateral macular degeneration and visual acuity below driving standards caused a motor vehicle collision due to impaired vision. He sustained severe chest injuries including flail chest,…
43y · Male·Multi-organ failure with coagulopathy secondary to acute exacerbation of chronic…
A 43-year-old man with a colloid cyst of the third ventricle presenting with progressive headache was admitted for planned endoscopic surgery. Surgery was delayed from Friday to Monday due to unavailability of specialist…
79y · Male·aspiration pneumonia
Giuseppe Dilettoso, aged 79, died of aspiration pneumonia at a nursing home where he was detained under guardianship orders. He had suffered two significant head injuries (2000 and 2013), with the latter requiring emerge…
59y · Female·Hypoxic ischaemic brain injury secondary to compression of the neck in the circu…
A 59-year-old woman with major depression died by hanging using her dressing gown tie while a voluntary inpatient at a private psychiatric clinic. She was assessed as low-risk and had no restriction on ligature access. D…
67y · Male·respiratory failure with antecedent causes including chronic emphysematic lung d…
67-year-old male with 40-year smoking history presented with chest symptoms in 2012. CT scan revealed a left upper lobe mass. Core biopsy was incorrectly reported as adenocarcinoma by the pathologist, despite clinical un…
35y · Male·hypoxic-ischaemic encephalopathy (post cardiac arrest) on a background of acute …
A 35-year-old man died by hanging in a medium-security prison while on remand. He was found unresponsive in his cell with a ligature around his neck. Despite immediate CPR, transfer to hospital and transfer to ICU at Fli…
67y · Female·perforated sigmoid volvulus with peritonitis upon a background of spinocerebella…
Betty Irene Ball, aged 67, died from perforated sigmoid volvulus with peritonitis on 2 February 2016. She had spinocerebellar ataxia and was resident in aged care. She developed constipation from 15 January 2016, but med…
50y · Male·Multiple pulmonary thromboemboli due to deep vein thrombosis following pharyngea…
A 50-year-old man died from pulmonary thromboembolism following uvulopalatopharyngoplasty (UPPP) surgery for obstructive sleep apnoea. Critical failures in post-operative management at a private hospital included: failur…
41y · Male·large volume thrombotic stroke within the distribution of the right posterior ce…
A 41-year-old man with acute posterior circulation stroke was misdiagnosed as encephalitis despite normal lumbar puncture findings. The critical failure was Dr R.'s failure to diagnose stroke on 7 September and arrange u…
59y · Female·Multiorgan failure and polymicrobial sepsis secondary to severe bone marrow fail…
A 59-year-old woman with renal transplant died from multiorgan failure and sepsis secondary to severe bone marrow failure caused by azathioprine toxicity. She had an undiagnosed genetic polymorphism (TPMT *3A/*3A homozyg…
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…
72y · Male·Subdural haematoma in a man receiving warfarin treatment
A 72-year-old man with intellectual disability receiving 24-hour support from DHHS died from acute subdural haematoma while on warfarin therapy post-cardiac surgery. He collapsed at work with vomiting and vagueness, was …
49y · Male·Hypoxic ischaemic brain injury complicating neck compression in the circumstance…
Anthony Sean Jenkins, a 49-year-old man with significant alcohol consumption, died by hanging on 30 August 2017 after police notified him of child sexual abuse allegations made by his daughter on 23 August 2017. He was f…
41y · Male·Complications of blunt force injuries of the head
Colin Parker, aged 41, suffered an unwitnessed fall with head injury while experiencing syncope from atrial fibrillation in early May 2014. He was admitted to Campbelltown Hospital but his serious intracranial pathology …
31y · Male·Hypoxic ischaemic brain injury secondary to hanging
Craig Akerblom, a 31-year-old man with depression, anxiety, substance abuse, and selective eating disorder, died by hanging resulting in hypoxic-ischaemic brain injury. He had been under care of multiple clinicians (GP, …
2y · Male·Group A beta Haemolytic Streptococcal septicaemia (invasive Group A Streptococca…
A 2-year-7-month-old boy died of Group A Streptococcal septicaemia after three presentations to hospital over three days. Clinical staff failed to recognise the developing bacterial infection despite objective warning si…
39y · Male·Complications of large bowel pseudo-obstruction
A 39-year-old man with schizo-affective illness, hepatic cirrhosis, and substance abuse history died from complications of large bowel pseudo-obstruction with aspiration pneumonia. He had been admitted involuntarily for …
76y · Male·Coronary atherosclerosis in the context of obesity, obstructive sleep apnoea, an…
A 76-year-old man with significant comorbidities including severe obstructive sleep apnoea, obesity, aortic stenosis, and ischaemic heart disease died from acute coronary atherosclerosis 36 hours after elective sacroilia…
22y · Female·Hypoxic-ischaemic encephalopathy due to asphyxia (mechanical asphyxiation by nec…
A 22-year-old woman died from asphyxia following strangulation by her boyfriend with schizophrenia. The boyfriend was under mental health service care at Princess Alexandra Hospital. The coroner found his mental health t…
13y · Male·borderline myocarditis, most likely due to influenza A virus infection
A 13-year-old previously healthy boy with borderline myocarditis presented to an adult ED with flu-like symptoms, lethargy, dizziness, syncope and inability to walk unaided. Despite these concerning features, he was disc…
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