133 results for “acute on chronic heart failure”
74y · Male·small intestinal ischaemia caused by aortic atherosclerosis
…chaemic bowel was not diagnosed until 9pm when he was critically ill with septic shock and multiple organ failure. By then, his entire small intestine was dead and surgery could not save him. Key failures included: not …
Multiple stab wounds to chest (David Gerard: stab wound to chest piercing heart;…
… while unwell and under-medicated, despite a 10-year history of violent behaviour and non-compliance. Key failures: inadequate discharge planning and community follow-up for Butler; premature discharge of Simper despite…
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…
66y · Female·urinary tract infection with contributing hypertensive heart disease, diabetes m…
…ated urinary tract infection (CAUTI) despite key clinical indicators: abnormally low temperature (35.5°C), acute pelvic pain, and urinalysis positive for leucocytes, nitrites, and protein. The SAAS paramedics' report do…
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…
Unknown·COVID-19 infection with various comorbidities as contributing factors
…ol, severe staffing shortages, and suboptimal clinical management under a Hospital-in-the-Home model. Key failures included: delayed PCR testing allowing spread, incomplete Advance Care Plan discussions, inadequate pain…
58y · Male·acute bronchopneumonia
Giovanni Trotta, aged 58, died in custody from acute bronchopneumonia. He was a vulnerable prisoner with COPD, schizoaffective disorder, and profound deafness.…
68y · Male·surgical complications following laparoscopic cholecystectomy for cholecystitis,…
…d man with multiple comorbidities, died from surgical complications after laparoscopic cholecystectomy for acute cholecystitis. Postoperatively, he developed profound hypotension. The treating team disagreed on whether …
76y · Female·hospital acquired pneumonia, multiple organ dysfunction and small bowel obstruct…
…umonia, multiple organ dysfunction, and small bowel obstruction. She was admitted to a rural hospital with acute renal failure and dangerously high potassium levels (8.1 and 7.6 mmol/L). Despite clear evidence of severe…
33y · Male·Longstanding atheromatous coronary artery disease with severe stenosis and cardi…
…cilitated detection of cardiac symptoms. However, the coroner found no individual culpability or systemic failure directly causing death, as the presentation was atypical and the underlying disease was not previously de…
83y · Male·pneumonia and severe acute respiratory distress syndrome caused by Legionella ba…
… initially misdiagnosed as having aspiration pneumonia rather than community-acquired pneumonia. Critical failures included: (1) radiology report showing pneumonia not communicated urgently by telephone to treating doct…
86y · Male·Septic shock secondary to urosepsis
…as readmitted next day with sepsis from a resistant urinary tract infection and died of septic shock. Key failures included: failure to review progress notes and blood test results before discharge, inadequate fluid bal…
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 …
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