445 results
22y · Female·bowel obstruction due to faecal impaction
Susan Windie, a 22-year-old with rare congenital abnormalities affecting bowel function, died from bowel obstruction due to faecal impaction complicated by abdominal compartment syndrome. She presented to Carnarvon Hospi…
0y · Female·hypoxic ischaemic encephalopathy secondary to intrapartum hypoxia
A 2-day-old neonate, Laura Angela Willmett, died from hypoxic-ischaemic encephalopathy following intrapartum hypoxia. She was born by emergency caesarean section after a planned vaginal birth after caesarean (VBAC) at a …
57y · Male·Multiple injuries sustained by being struck by a freight train
A 57-year-old man with 28-year history of treatment-resistant schizophrenia died by suicide when he absconded from an acute psychiatric unit and stepped in front of a train. Despite comprehensive psychiatric management i…
85y · Female·Multisystem failure complicating ischaemic heart disease and ischaemic bowel in …
Lydia Maxfield, 85, died 5 days after elective left total knee replacement at a private hospital from multisystem failure due to ischaemic heart disease and ischaemic bowel. Critical clinical lessons: (1) Multiple abnorm…
44y · Male·Cardiac arrhythmia during physical restraint
Taare Rangi, a 44-year-old man with bipolar affective disorder, died from cardiac arrhythmia during physical restraint in a mental health unit. Critical failures occurred at multiple levels: (1) the decision to acutely s…
66y · Male·respiratory infection on a background of metastatic carcinoma
Thomas Kedwell, aged 66, died in custody at Prince of Wales Hospital from respiratory infection secondary to metastatic carcinoma. He had undergone laryngectomy and tracheostomy for throat cancer in 2017, and presented w…
68y · Male·Pulmonary thromboembolus secondary to deep vein thrombosis
Ronald Wood, a 68-year-old with complex medical history including prior pulmonary emboli, was treated for rectal cancer requiring chemotherapy and major surgery. Warfarin anticoagulation was appropriately ceased due to b…
33y · Female·Hypoxic ischaemic encephalopathy complicating mixed drug toxicity
Jessica Higgins, a 33-year-old woman with chronic pain on high-dose opioids, underwent ketamine infusion with planned opioid rotation to methadone in May 2017. She was discharged on 23 May on methadone 5mg twice daily pl…
18y · Female·Generalised tonic-clonic seizure and cardiac arrest arising from severe hyperten…
An 18-year-old pregnant woman presented in labour at 41 weeks and 2 days gestation. From 23 September onwards, she experienced intermittent headaches, epigastric pain, proteinuria and peripheral oedema. At 1755 hours on …
65y · Male·ischaemic heart disease following complications of colorectal surgery
A 65-year-old man with significant comorbidities (cardiomyopathy, diabetes, obesity) underwent colorectal surgery for adenocarcinoma. Post-operative course was complicated by anastomotic breakdown causing sepsis on day 1…
56y · Male·Pulmonary embolism with deep vein thrombosis an antecedent cause; coronary arter…
Peter Robin, a 56-year-old man with a medical history of hypercholesterolaemia, hypertension, obesity, and depression, underwent elective dental surgery on 28 October 2015 to remove four wisdom teeth and resect a cyst. H…
81y · Female·hypovolemic shock due to haemorrhage during orthopaedic repair of a femur fractu…
Margaret Ann Whitney, an 81-year-old woman with vascular dementia, died from hypovolemic shock due to haemorrhage during orthopaedic surgery for a femoral fracture sustained in a fall at her nursing home. She had been su…
60y · Male·Haemorrhage complicating a left robotic upper mediastinal lymph node clearance i…
Brett Maybus, aged 60, died from massive haemorrhage following robotic mediastinal lymph node dissection for recurrent metastatic squamous cell carcinoma. The coroner found the fatal bleed was likely caused by rupture of…
5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …
A five-year-old child with complex neurodevelopmental conditions and polypharmacy (including valproic acid for epilepsy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with ora…
87y · Female·Hypoxic-ischaemic encephalopathy secondary to cardiac arrest, with valvular hear…
An 87-year-old woman died following a CT-guided epidural injection at a private radiology clinic. Although she had undergone the procedure for spinal pain, the radiologist performed an epidural injection at the T12 level…
18y · Male·Incised wound to right axilla with complete transection of basilic vein, brachia…
Thomas Redman, aged 18, sustained a catastrophic laceration to his right axilla involving complete transection of major arteries and veins after putting his arm through a glass window at a rural property near Gloucester,…
19y · Female·2,4-dinitrophenol toxicity
A 19-year-old woman died from 2,4-dinitrophenol (DNP) toxicity after intentionally ingesting approximately 50 x 250mg capsules purchased online. She presented to Flinders Medical Centre with an Inpatient Treatment Order …
61y · Female·multi organ failure due to abdominal sepsis
Lesley Arndell, aged 61, died from multi-organ failure due to abdominal sepsis after undergoing a Whipple's procedure for pancreatic cancer. Key clinical lessons include: (1) patients with previous bariatric surgery requ…
83y · Male·aspiration pneumonia and delirium complicating surgery for left total knee repla…
An 83-year-old man with dementia and ischaemic heart disease underwent elective left total knee replacement under spinal anaesthesia to avoid general anaesthesia, as advised by geriatrician. Despite optimal anaesthetic t…
89y · Female·Aspiration pneumonia complicating electroconvulsive therapy for treatment of psy…
Hilda Berg, 89-year-old woman with depression, psychosis, atrial fibrillation, chronic kidney disease and type 2 diabetes, deteriorated in hospital with refusal to eat or drink due to psychotic beliefs. After initial con…
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