1,488 results
69y · Female·Multiple organ failure due to secondary haemochromatosis (transfusion-associated…
Mrs Vicki Dow, 69, died from multiple organ failure secondary to iron overload (transfusion-associated haemochromatosis) from treatment of myelodysplastic syndrome. She had declined iron chelation therapy for 19 months d…
62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…
A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…
69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…
Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…
46y · Male·Aspiration pneumonia complicating epistaxis in the setting of prolonged nasal pr…
Hau Bui Nguyen, a 46-year-old man with severe acquired brain injury, dysphagia, and recurrent aspiration pneumonia, died from aspiration pneumonia complicating epistaxis following prolonged nasal prong oxygen therapy. Du…
69y · Male·thoracic aortic aneurysm with dissection
Peter Hanisch, a 69-year-old man, died from thoracic aortic aneurysm with dissection on 22 August 2021. He presented to Calvary Hospital on 19 August 2021 with sudden chest discomfort and neurological symptoms. A CT angi…
81y · Male·Community acquired pneumonia in a man with acute on chronic renal failure
An 81-year-old man with chronic respiratory disease and renal failure died from community-acquired pneumonia complicated by acute-on-chronic renal failure. He presented to hospital on 25 April 2023 with respiratory failu…
33y · Male·hypoxic-ischaemic encephalopathy due to hanging with resuscitation
Matthew Keith Constantine, aged 33, died from hypoxic-ischaemic encephalopathy following a hanging attempt while under home detention. He was released from prison in December 2021 with parole conditions including electro…
43y · Male·Hypoxic ischaemic encephalopathy, due to or as consequence of, cardiac arrest of…
A 43-year-old man with methamphetamine toxicity was restrained by police and given two doses of droperidol by paramedics who failed to recognize he was critically unwell. The first dose was clinically indicated, but the …
86y · Female·Pulmonary thromboembolism in the setting of deep leg vein thrombosis, secondary …
Barbara Deal, 86, died from pulmonary embolism secondary to deep vein thrombosis 17 days after lumbar spinal fusion surgery. Critical failures included: no repeat VTE risk assessments despite policy requirements; inconsi…
62y · Male·cardiac arrhythmia secondary to prolongation of the QT interval
NL, a 62-year-old man with schizoaffective disorder and hypothyroidism, died of cardiac arrhythmia secondary to QT prolongation while an involuntary mental health inpatient. He had a known history of non-compliance with …
66y · Female·Hypoxic-ischaemic encephalopathy
A 66-year-old woman with COPD, obstructive sleep apnoea, and obesity underwent routine knee surgery at Royal Darwin Hospital. Post-operative care was inadequate. Despite dropping oxygen saturations to 88% when sedated an…
65y · Female·Status epilepticus complicating cerebral palsy
Ms Francis, a 65-year-old woman with cerebral palsy and intellectual disability, died from status epilepticus after multiple hospital admissions for aspiration pneumonia and declining functional status. She had recurrent…
41y · Male·complications of acute ethanol toxicity
Mr RJ, a 41-year-old man with a history of progressive alcohol misuse and mental health conditions (anxiety and depression), died from complications of acute ethanol toxicity following cardiac arrest due to aspiration an…
77y · Female·intracranial haemorrhage (subdural, intraventricular and brainstem)
A 77-year-old woman fell from a ladder on 12 December 2022, suffering loss of consciousness and rib fractures. No brain CT scan was performed at Mersey Community Hospital despite the mechanism of injury and unconsciousne…
5y · Male·Complications of burns
A 5-year-old boy died from complications of severe burns sustained during a fuel ignition incident at his father's rural property. While refuelling a small motorcycle, the father failed to shut off the engine and did not…
11y · Female·Pneumonia complicating cerebral palsy secondary to KCNQ2 developmental and epile…
HD was an 11-year-old girl with severe cerebral palsy, epilepsy, and multiple complex medical conditions including central respiratory depression and recurrent chest infections. She died from pneumonia at home in August …
75y · Female·multiple organ failure due to severe anaemia secondary to blood loss post electi…
A 75-year-old woman died from multiple organ failure due to severe anaemia after elective hysterectomy surgery. Critical failures occurred: the surgical and anaesthetic teams held conflicting understandings about whether…
73y · Female·Complications of lipoid pneumonia following the ingestion of shampoo, conditione…
Judith Pollard, a 73-year-old woman with an extensive mental health history, was voluntarily admitted to Shepparton Private Hospital on 1 June 2023 following acute depression and paranoia. Despite her family informing st…
73y · Male·Complications of multiple injuries sustained in a motor vehicle incident (car vs…
A 73-year-old man with extensive medical comorbidities including severe biventricular heart failure, COPD, sleep apnoea, and hypertension experienced a medical episode while driving, causing him to cross into oncoming tr…
43y · Female·Severe diffuse hypoxic brain injury caused by administration of supratherapeutic…
A 43-year-old woman died from severe diffuse hypoxic brain injury caused by excessive sodium bicarbonate administration during treatment of amitriptyline overdose. The treating ED consultant prescribed sodium bicarbonate…
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