54y · Male·Hypoxic/ischaemic brain damage caused by blood loss and airway obstruction due t…
… deteriorated into cardiac arrest requiring 97 minutes resuscitation, resulting in hypoxic-ischaemic brain injury from which he could not recover.
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…
0y · Female·Perinatal asphyxia
Baby M was born at 38+4 weeks gestation in poor condition at The Royal Women's Hospital on 10 November 2022 and died at 24 minutes of age from perinatal asphyxia. Autopsy findings suggested cord compression occurring 4-6…
74y · Male·Sepsis secondary to infected pressure wounds (necrotising fasciitis) in a man wi…
A 74-year-old man with multiple comorbidities (diabetes, obesity, respiratory failure, mental health conditions) died from sepsis secondary to necrotising fasciitis of pressure wounds developed while in aged care. Key cl…
75y · Male·multifactorial causes on a background of ischaemic heart disease, generalised va…
Robert Bischard, a 75-year-old man with multiple complex comorbidities including coronary artery disease, chronic kidney disease, and diabetes, died five days after elective right total knee replacement surgery. The coro…
85y · Male·Heat stroke
An 85-year-old man with dementia, diabetes, and aortic stenosis died from heat stroke after spending 2 hours 18 minutes unmonitored in an unsheltered outdoor garden area at a residential aged care facility. The resident …
75y · Female·Ischaemic heart disease in the setting of unstable type 2 diabetes mellitus and …
Veronica Roberts, 75, died from ischaemic heart disease complicated by unstable diabetes and a medication error. On 4 October 2020, her insulin dose was increased to 20 units daily, but due to Electronic Medical Record (…
52y · Female·laceration of the superior vena cava and right atrium during defibrillator lead …
A 52-year-old woman with a history of syncope and mitral valve prolapse, who had an implanted defibrillator, underwent a percutaneous laser lead extraction procedure at Westmead Hospital to remove and replace defective l…
50y · Male·Complications of right buttock necrotising fasciitis secondary to chronic right …
50-year-old male with chronic pain from jockey injuries became dependent on morphine. General practitioner prescribed intramuscular (IM) morphine for self-administration at home from 2005–2007 at doses of 120–240mg daily…
26y · Male·gunshot wound to the neck
…arm; Roberts returned fire while retreating, with a bullet hitting Crews in the neck causing unsurvivable vascular injuries. Systemic failures contributed: inadequate risk assessment methodology, poor supervision of plan…
28y · Male·hypovolemia secondary to haemorrhage from operative exploration of multiple stab…
A 28-year-old Aboriginal male died from hypovolemic shock following operative exploration of multiple stab wounds to the thigh. The death was preventable. Critical failures included: delayed surgery from Friday to Saturd…
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