126 results for “radiology imaging”
78y · Female·multi-organ failure due to haemorrhage into the abdomen, pelvis and retroperiton…
… the posterior approach but surgery continued without re-exploration of the anterior site. Post-operative imaging failed to identify the bleeding source, though autopsy revealed significant haemorrhage. Expert reviewers…
1y · Female·acute myocardial infarction secondary to Kawasaki's Disease
Kristen Kerkvliet, aged 14 months, died from acute myocardial infarction secondary to Kawasaki's Disease. She presented to Gympie Hospital severely underweight and malnourished on 3 February 2006, having failed to thrive…
73y · Male·sepsis due to ischemic gut due to occlusion of the superior mesenteric artery
A 73-year-old man presented with acute severe abdominal pain caused by superior mesenteric artery (SMA) occlusion. Initial CT angiogram at 12:30am was reported as normal; the SMA occlusion was not identified until 4:45am…
Male·Hemant Chadha: acute on chronic pneumonia (mycoplasma pneumoniae). Sachintha Bat…
…esentation with moderate-to-frank haemoptysis, he was again discharged without admission despite abnormal imaging, partly due to language barriers and failure to review video evidence. Both deaths were preventable with …
20y · Female·Aspiration of sand; cause of sand aspiration not determined
Elly Warren, a 20-year-old Australian volunteer worker, died in Mozambique on 9 November 2016 from aspiration of sand. The coroner found the cause of death was sand obstruction of her airways, though the precise circumst…
69y · Male·Perforated bowel/septicaemia as a result of diverticulitis
A 69-year-old man presented to the ED with abdominal distension, incontinence and dehydration but was discharged with a diagnosis of depression and constipation. He returned 2 days later critically unwell and died of per…
67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…
…admission; complete neurological assessment; involving family in care planning; and exploring alternative imaging options or positioning techniques. A sentinel event review identified multiple failures including trauma …
56y · Male·disseminated nocardiosis involving central nervous system, kidneys, liver and th…
…his 12-day RAH admission. Clinicians initially suspected metastatic lung cancer based on presentation and imaging, which was objectively reasonable. Two CT-guided biopsies on 8-9 November were attempted but unsuccessful…
87y · Female·Oesophageal perforation following an elective oesophageal dilatation, secondary …
87-year-old Helen Mahlis died from oesophageal perforation following an elective balloon dilation procedure at Epworth Richmond for treatment of achalasia. The coroner identified two contributing factors: use of a 35mm b…
53y · Male·metastatic pancreatic cancer
Joseph Mallia, a 53-year-old man incarcerated at Barwon Prison, presented with left flank pain and haematuria in November 2011. A CT scan in January 2012 identified concerning pancreatic duct distension suggesting possib…
53y · Female·sepsis and multiple organ failure attributable to infarction/necrosis of small b…
…the occluded SMA. The patient underwent a non-diagnostic laparoscopy at 6:00 PM. Diagnosis was made at a radiology meeting at 8:30 AM on 20 August—36 hours after symptom onset—when a colorectal surgeon identified the SM…
61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed
A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…
40y · Male·Subarachnoid haemorrhage due to ruptured right middle cerebral artery aneurysm
…and quickly diagnosed with subarachnoid haemorrhage due to ruptured middle cerebral artery aneurysm on CT imaging at 8:42pm. He collapsed in the waiting room and was intubated. Urgent transfer to neurosurgery was arrang…
83y · Female·Pneumonia complicating rib and pelvic fractures sustained in the setting of mult…
Margaret Barton, 83, died of pneumonia complicating rib and pelvic fractures from multiple falls. Critical clinical lessons: (1) The Oxazepam regimen directly contributed to her death. Dr C. tripled her dose from 15mg to…
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…
6y · Male·pneumonia complicating influenza A (H1N1) infection with secondary streptococcal…
Sebastian Parman, a 6-year-old boy, died from pneumonia complicating influenza H1N1 with secondary group A streptococcal infection causing scarlet fever, empyema and sepsis. Multiple clinical failures contributed: an inf…
<1y · Male·Head injury in the setting of chronic subdural haemorrhage
… January, while in the care of his mother's partner Mr Vinaccia, Kaleb suffered cardiorespiratory arrest. Imaging revealed new bilateral subdural haematomas, retinal haemorrhages and extensive hypoxic brain injury consi…
<1y · Male·Complications in association with fulminant sepsis in an infant (Streptococcus p…
Malakai Paraone, a seven-month-old infant, died from fulminant Streptococcus pyogenes sepsis and septic shock. Over three days, he was seen at three hospitals and a general practice clinic but sepsis was not identified. …
26y · Female·Pulmonary embolism as a consequence of dislodged deep vein thrombosis
…ses, DVT prophylaxis and monitoring critical in immobilised patients with obesity, and robust handover of imaging results imperative.
78y · Male·metastatic malignancy (unknown primary) with contributing right-sided heart fail…
…-month delay. A urologist visited Port Lincoln monthly but Dodson was not referred until October 2012. CT imaging in March 2013 revealed liver metastases; prostate cancer entered remission with hormone therapy but liver…
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