32 results
22y · Male·Airway obstruction due to laryngeal abscess and laryngeal chondronecrosis due to…
Kyle Gallagher, age 22, died from airway obstruction due to laryngeal abscess and chondronecrosis following a motorcycle accident. A CT scan on 13 July 2023 showed a critically narrowed (3mm) subglottic airway with suspe…
49y · Female·Hypoxia due to complications following incision and drainage of a right buttock …
A 48-year-old woman with multiple comorbidities (diabetes, COPD, chronic kidney disease, ischaemic heart disease) died following complications of anaesthesia during incision and drainage of a buttock abscess. Critical fa…
32y · Female·Cardiac arrest due to hypoxia caused by dynamic hyperinflation arising from comp…
A 32-year-old woman with Sponastrime Dysplasia (a rare genetic bone disorder) died during elective bariatric surgery. She had undiagnosed subglottic stenosis (airway narrowing) and tracheobronchomalacia. Critical clinica…
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…
54y · Male·Hypoxic/ischaemic brain damage caused by blood loss and airway obstruction due t…
A 54-year-old male was assaulted in a nightclub with a single punch causing orbital and facial fractures and posterior epistaxis. He presented to the Royal Hobart Hospital ED with active bleeding. Critical deficits in hi…
20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…
Adam Fitzpatrick, a 20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged…
65y · Female·undetermined; possibly ischaemic heart disease or squamous cell carcinoma of ton…
A 65-year-old Malaysian woman with advanced squamous cell carcinoma of the tongue refused medical treatment due to visa concerns and preference for alternative therapy. She deteriorated over months with worsening oral sy…
84y · Male·Respiratory failure complicating hospital acquired pneumonia following surgical …
An 84-year-old man died from respiratory failure due to hospital-acquired pneumonia following surgery for recurrent mandibular squamous cell carcinoma. Key clinical lessons: (1) Advanced Care Plans (ACPs) must be activel…
49y · Female·Hypoxic brain injury related to tracheostomy complications in form of airway occ…
Andrea Lester, age 49, suffered a subarachnoid haemorrhage from a PICA aneurysm in March 2018 with delayed diagnosis. Following complex neurosurgery causing Wallenberg syndrome, she required tracheostomy for bulbar dysfu…
71y · Male·sepsis caused by mediastinal empyema (abscess) which complicated perforation of …
Terence Carroll, 71, died from sepsis and mediastinal empyema following oesophageal perforation during rigid oesophagoscopy for stricture dilation. Critical failures included: CT scan showing suspicious oesophageal thick…
71y · Male·Complications of metastatic squamous cell carcinoma (terminal palliation)
Leslie Shortte, a 71-year-old life prisoner, died from metastatic squamous cell carcinoma with complications. Critical failures in his prison medical care included: failure to complete annual health assessments after 201…
44y · Male·Complications of a Left Temporal Lobe Abscess
Mootijah was a 44-year-old Aboriginal man who died from a brain abscess originating from an untreated chronic ear infection. He had documented hearing impairment and a history of chronic ear disease requiring ENT special…
42y · Male·hanging
A 42-year-old prisoner with generalised anxiety disorder and chronic tinnitus causing significant distress died by suicide while incarcerated. In the months preceding his death, he presented repeatedly to health staff re…
69y · Male·Hypoxic ischaemic brain injury secondary to right facial artery pseudoaneurysm r…
69-year-old male with tonsillar squamous cell carcinoma presenting with throat pain and trismus 12 days after completing chemoradiotherapy. On presentation to emergency department with bleeding, airway risk was under-rec…
78y · Male·cardiorespiratory failure due to complications of tracheal stenosis
Bruce Hodges, a 78-year-old man with a 20-year-old tracheostomy following laryngeal cancer surgery, presented to hospital with progressive shortness of breath and tracheal stenosis. Over 48 hours of admission, his respir…
52y · Female·Neutropenic sepsis leading to multi-organ failure due to capecitabine toxicity
Mrs L, a 52-year-old woman with T2N0M0 rectal cancer, died from neutropenic sepsis and multi-organ failure secondary to severe capecitabine toxicity on 31 October 2018. She commenced neoadjuvant chemotherapy with capecit…
76y · Female·Ludwig's angina
A 76-year-old woman with Ludwig's angina presented to urgent care with facial swelling and fever. She was appropriately diagnosed and arrangements made for transfer to a tertiary centre. However, staff failed to recognis…
25y · Female·Airway obstruction complicating laryngeal dilation for the treatment of subglott…
Ms Sobb, a 25-year-old woman with spondylo-epi-metaphyseal dysplasia causing severe airway abnormalities and subglottic stenosis, died from airway obstruction following laryngeal dilation. She was admitted to ICU with as…
12y · Female·Cardio-respiratory failure due to aspiration pneumonia
Angelique Burton-Ho, age 12, with VACTERL syndrome and difficult airway, presented to Bowral Hospital ED on 9 August 2015 with respiratory symptoms. She was inadequately triaged initially, then readmitted that evening wi…
50y · Male·Multiple pulmonary thromboemboli due to deep vein thrombosis following pharyngea…
A 50-year-old man died from pulmonary thromboembolism following uvulopalatopharyngoplasty (UPPP) surgery for obstructive sleep apnoea. Critical failures in post-operative management at a private hospital included: failur…
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