0y · Female·subgaleal haematoma complicating an obstructed labour
…rm infant born following obstructed labour, died at four days of age from subgaleal haemorrhage (SGH) with severe hypoxic-ischaemic encephalopathy. Labour was managed by private obstetrician Dr K., who was not physically…
26y · Female·meningococcal infection (Neisseria meningitidis W strain) causing septicaemia
…eningococcal septicaemia (W strain) within 3 hours of arriving at Royal Perth Hospital. She presented with severe generalised pain (10/10), tachycardia, hypothermia, and vomiting. Clinical lessons include: (1) ED overcro…
0y · Male·Perinatal hypoxic ischaemic encephalopathy with severe diffuse cortical necrosis…
George Darcy Key, an 8-day-old neonate, died from perinatal hypoxic ischaemic encephalopathy following labour complicated by excessive syntocinon-induced contractions and delayed obstetric intervention. The infant was de…
11y · Male·Sepsis
An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…
2y · Male·Hypoxic ischaemic encephalopathy and intracranial haemorrhage complicating obstr…
A term infant died on day 2 of life from hypoxic-ischaemic encephalopathy and intracranial haemorrhage following obstructed labour requiring emergency caesarean section. The mother presented in spontaneous labour at 39 w…
59y · Male·ischaemic heart disease in the context of acute-on-chronic kidney failure associ…
Arthur James Bonney, a 59-year-old prisoner with advanced cardiac disease, chronic kidney disease, and diabetes, underwent a CT scan with iodinated contrast on 30 July 2015 at Fiona Stanley Hospital. Critical failures oc…
44y · Male·gunshot wound to abdomen
A 44-year-old male died from a gunshot wound to the abdomen sustained during a police response to a domestic violence incident. He became aggressive, wielded a knife, and lunged at police after Taser and pepper spray fai…
65y · Female·Combined effects of acute pneumonia, pancreatitis, urinary tract infection, and …
…ive functional decline died from combined effects of pneumonia, pancreatitis, urinary tract infection, and severe pressure ulcers with osteomyelitis following a prolonged lie at home. She had been largely bedridden for y…
4y · Male·Peritoneal sepsis caused by a perforated duodenal ulcer
A 4-year-old boy with significant global developmental delay and non-verbal communication died from peritoneal sepsis caused by a perforated duodenal ulcer. Presentation included lethargy, poor oral intake, low haemoglob…
0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the sett…
Mia Rose Iskander died at 8 hours of age from ascending uterine infection (Klebsiella pneumoniae) with chorioamnionitis following maternal premature pre-labour rupture of membranes (PPROM) at 32 weeks. Maternal managemen…
0y · Female·Cerebral hypoxia due to placental abruption
Sophie Sparreboom died from cerebral hypoxia secondary to placental abruption following emergency caesarean section. Gestational diabetes indicated planned induction at term. At 2050 hours, antepartum haemorrhage and pat…
0y · Female·Sepsis
…hours prior to delivery. The infection caused chorioamnionitis with profound foetal inflammatory response, severely compromising the baby before labour commenced. Clinical lessons: (1) Patients declining evidence-based i…
82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis
An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was …
21y · Female·Multiple organ failure as a result of overwhelming Streptococcus pyogenes (Group…
…ed by necrotising fasciitis (Group A Streptococcus) on 14 October 2011, presenting 8 days post-partum with severe leg pain and multiple signs of sepsis. Critical failures included: absence of sepsis recognition protocols…
76y · Female·hospital acquired pneumonia, multiple organ dysfunction and small bowel obstruct…
… acute renal failure and dangerously high potassium levels (8.1 and 7.6 mmol/L). Despite clear evidence of severe illness requiring urgent transfer to a tertiary centre, she remained at the rural hospital for approximate…
0y · Male·hypoxic ischaemic encephalopathy
…ivery on 1 March 2005. After artificial rupture of membranes during labour induction, the foetus developed severe, sustained bradycardia lasting approximately 30 minutes before delivery. The emergency caesarean section d…
Toxicity from intravenous caesium, DMSO, and other substances administered as pa…
In May 2005, the Kathi Preston Memorial Health Centre (KPMHC) operated an unproven cancer therapy clinic from Dr B.'s home in Perth, Western Australia, administering intravenous treatment containing caesium, DMSO, and La…
17y · Male·Hypoxic Ischaemic Encephalopathy Complicating Anaphylaxis
James Tsindos, a 17-year-old with known nut allergy and mild asthma, experienced anaphylaxis after inadvertently ingesting cashews in a vegan restaurant meal on 27 May 2021. Ambulance paramedics administered two doses of…
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