31y · Male·Complications in association with intestinal volvulus
…rnoon, he was critically unwell with intestinal volvulus, sepsis and pneumonia. He died despite emergency surgery preparation. Key failures included: absence of supporting care worker at initial ED visit, inadequate dis…
13y · Male·chest and abdominal injuries sustained in collision between semi-trailer and tra…
A 13-year-old boy, Matthew Stubbs, died when a semi-trailer collided with a V/Line passenger train at the Kerang level crossing on 5 June 2007, killing 11 train passengers total. The driver failed to see the train despit…
Male·Hemant Chadha: acute on chronic pneumonia (mycoplasma pneumoniae). Sachintha Bat…
Two young men died after repeated ED presentations were not appropriately managed. Hemant Chadha (38) died of acute pneumonia complicated by possible neurological involvement after being discharged from Lyell McEwin Hosp…
0y · Male·Complications of hypoxic ischaemic encephalopathy secondary to recurrent episode…
Kyran Day, a 6-month-old boy, presented to Shoalhaven District Memorial Hospital with vomiting and lethargy on 19 October 2013. He was initially assessed and diagnosed with gastroenteritis based on recent rotavirus vacci…
87y · Female·combined effects of ischaemic heart disease and chronic obstructive pulmonary di…
Epenesa Pahiva, 87-year-old resident with dementia at an aged care facility, suffered severe chemical burns from inappropriate bleach treatment prescribed by dermatologist Dr B.. The coroner found the treatment itself (h…
73y · Male·Acute intracranial haemorrhage, due to or as a consequence of coagulopathy, due …
Mr Stimpson, a 73-year-old man, died from massive intracerebral haemorrhage secondary to coagulopathy caused by inadvertent double administration of anticoagulants (Clexane and Xarelto). He developed bilateral pulmonary …
42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…
Eve Brown, a 42-year-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ri…
49y · Female·Hypoxic brain injury related to tracheostomy complications in form of airway occ…
…ubarachnoid haemorrhage from a PICA aneurysm in March 2018 with delayed diagnosis. Following complex neurosurgery causing Wallenberg syndrome, she required tracheostomy for bulbar dysfunction. On 13 June 2018, she suffe…
2y · Unknown·Hypoxic-ischaemic encephalopathy following sepsis related to abdominal surgical …
BCT was a 2-year-old Aboriginal child with complex needs from a genetic disorder (CAMTA1 mutation) who died from hypoxic-ischaemic encephalopathy following sepsis related to bowel perforation after a percutaneous endosco…
56y · Male·acute pentobarbitone toxicity
Ross Martin, a 56-year-old man with a long history of depression, died from acute pentobarbitone (Nembutal) toxicity obtained online, combined with toxic levels of zopiclone, less than two weeks after premature discharge…
78y · Female·cardiorespiratory failure, ischaemic and hypertensive heart disease together wit…
Barbara Francis, a 78-year-old resident with dementia at Pearl Supported Care in the dementia unit (Dinah), was punched by another resident (Mr A) on 4 September 2018 and fell backward onto her right hip, sustaining an o…
29y · Female·gunshot wound to the abdomen
Joyce Gladis Clarke, a 29-year-old Aboriginal woman, was fatally shot in the abdomen by First Class Constable Wyndham while police responded to a call about a person carrying a knife in a Geraldton street. Clarke had bee…
2y · Male·Group A Streptococcal toxic shock syndrome which probably originated in the thro…
Ryan Saunders, a 2-year-old boy, died from Group A Streptococcal toxic shock syndrome after a 72-hour presentation with fever, pain, and systemic illness. Initial GP care was appropriate given the presentation and diagno…
1y · Female·Multiple injuries (subdural clot, multiple rib fractures, injuries to liver, blo…
A 20-month-old girl died from fatal injuries inflicted by her mother's partner. She presented to hospital twice in two weeks with suspicious injuries: facial injuries on 7 June attributed to a puppy, and more extensive f…
79y · Female·multiple injuries sustained in collision between semi-trailer and train
On 5 June 2007, a semi-trailer collided with a V/Line passenger train at the Kerang level crossing, killing 11 train passengers. The driver had traversed this crossing many times in seven years without seeing a train, an…
30y · Male·Gunshot wounds to the chest
Gabriel Messo, a 30-year-old man with bipolar affective disorder, died from gunshot wounds inflicted by Victoria Police on 16 July 2020 after violently assaulting his mother at John Coutts Reserve. Clinical lessons inclu…
41y · Female·Peritonitis following surgical procedure to the urinary bladder, due to infected…
Cheryl Lee Edmiston, a healthy 41-year-old woman, died of peritonitis and sepsis following minor bladder procedures (cystoscopy, hydrodilatation, and biopsy) at Joondalup Health Campus on 14 February 2003. The biopsies w…
26y · Male·Multiple drug toxicity and bronchopneumonia
Daniel James Hall, aged 26, died on 31 July 2010 from multiple drug toxicity and bronchopneumonia after consuming approximately 10-12 OxyContin tablets over 24 hours, vastly exceeding the prescribed dose of one tablet ev…
45y · Female·multiple organ failure following thermal injuries (severe burns)
Wendy Bearfoot, a 45-year-old DEC (Department of Environment and Conservation) employee, died from multiple organ failure following severe thermal burns (80% of body) sustained in a bushfire burnover on 12 October 2012. …
31y · Male·Injuries sustained as a consequence of helicopter crash into water
Three emergency service personnel—pilot Andrew Carpenter (31), paramedic Craig Liddington (31), and crewman Stewart Eva (31)—died in a helicopter crash on 17 October 2003 during a night VFR flight to retrieve a patient w…
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