85y · Female·Pulmonary embolus secondary to deep vein thrombosis, precipitated by minor fall
An 85-year-old woman died from pulmonary embolism secondary to deep vein thrombosis following a minor fall. She was admitted to Maryborough Hospital with chest infection and abdominal pain. Despite being identified as hi…
76y · Male·Coronary atherosclerosis in the context of obesity, obstructive sleep apnoea, an…
…gnificant comorbidities including severe obstructive sleep apnoea, obesity, aortic stenosis, and ischaemic heart disease died from acute coronary atherosclerosis 36 hours after elective sacroiliac arthrodesis. Critical …
57y · Male·Severe coronary artery disease. It is likely that Kevin's use of inhalants in cu…
…l programs are essential; (6) excessive transfers undermine continuity of care and health engagement. The failure to escalate the June 2018 ECG showing previous myocardial infarction may have delayed diagnosis of life-t…
73y · Female·Bacterial endocarditis organism arising from a staphylococcal infection that ent…
… 73, received a 5-year custodial sentence in September 2004. She had complex medical needs: dementia from previous strokes, diabetes requiring insulin monitoring, and Warfarin use. Justice Health provided inaccurate info…
55y · Male·Acute myocardial infarction due to coronary thrombosis and coronary atherosclero…
… pain, sweating, and left arm pain—classic cardiac symptoms—but an ECG was not performed due to equipment failure. Subsequent VMOs who assessed him in December did not review earlier medical notes and diagnosed him with…
2y · Male·Group A beta Haemolytic Streptococcal septicaemia (invasive Group A Streptococca…
…linical staff failed to recognise the developing bacterial infection despite objective warning signs. Key failures included: not escalating care when presented with persistent tachycardia (HR 180) on the third visit; fa…
37y · Male·stab wound to the chest penetrating the heart
…ychiatric hospital on 11 April 2011 on voluntary arrangements without a community treatment order despite previous compliance only under legal compulsion. Over the following 10 days, he exhibited non-compliance with medi…
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…
78y · Female·cardiorespiratory failure, ischaemic and hypertensive heart disease together wit…
… physiotherapy recommendations that she wear hip protectors 24/7, she was not wearing them due to laundry failures. The fall triggered rapid deterioration; she underwent hemiarthroplasty but died 14 days later from card…
74y · Male·cardiac and renal failure complicating treatment of infected ischaemic toes resu…
…d ischaemic toe secondary to diabetes mellitus. During his 17-day hospital stay, he developed acute renal failure leading to cardiac arrest and death. Critical failures included: failure to monitor creatinine and gentam…
83y · Female·Aspiration bronchopneumonia in a setting of cerebral infarction
Ms Patricia Grant, 83, died from aspiration bronchopneumonia following cerebral infarction while living with her son and daughter-in-law. She experienced severe neglect and elder abuse in her final years: cessation of ep…
Unknown·Troy Monson: asphyxia due to partially suspended hanging using seatbelt; Robin M…
…hythmia from drug-induced cardiomegaly July 2015). Monson's death was preventable through multiple system failures: failure to identify suicide risk despite clear warning signs, inadequate assessment tools and tier proc…
41y · Male·Unable to be ascertained
…22 for psychotic behaviours and assault allegations. Discharged on oral risperidone despite poor insight, previous non-compliance, and prior treatment with community treatment order (CTO) and depot injections. Community …
49y · Male·Acute myocardial infarction complicating prosthetic valve thrombosis in a man wi…
…3.5) for mechanical valves, inadequate anticoagulation significantly increasing thrombosis risk. Systemic failures included incomplete discharge summaries not conveying anticoagulation details to community providers, po…
77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…
77-year-old male died from complications of haemothorax and hypotension following drainage of pleural effusion post-coronary bypass surgery, in the setting of pre-existing renal impairment and diabetes. During pleural ta…
44y · Male·Hanging
… coroner found the lack of communication between the RAT and Sentence Management was the most significant failure. While observations at 1:30pm and 2:00pm were inadequate, the coroner concluded Mr Blair would not have b…
71y · Female·multiple pulmonary thromboemboli and deep vein thrombosis
71-year-old woman presented to ED with signs of circulatory failure (hypotension, tachycardia, tachypnoea, hypoxia) and progressive leg pain/swelling over one week. ECG show…
Male·neck injury (laryngeal fracture from compression) in a man with atherosclerotic …
… inmate Evan Martin. Bropho was a vulnerable remand prisoner with intellectual disability, schizophrenia, previous myocardial infarction, and diabetes. The coroner found the Department of Justice missed a critical opport…
0y · Female·acute necrotising pneumonia
… doctor assessed her as having a viral cold and sent her home with paracetamol despite a recorded elevated heart rate (185 bpm) and reported fever. Her second presentation (4 October) was curtailed when family left afte…
smoke inhalation and burns from deliberately-lit fire (primary cause varies by i…
… nurse Roger Dean to destroy evidence of medication theft. Dean had worked while visibly intoxicated at a previous hospital (St John of God) but this was not communicated to Quakers Hill despite mandatory notification re…
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