52y · Male·C2, C3, C4 spinal injury sustained from a fall secondary to seizures
…C4). He was admitted to hospital with initially appropriate vital signs and neurological presentation. CT scanning was delayed by more than 15 hours due to difficulty understanding his neurological baseline, communicatio…
Male·Faecal peritonitis due to perforated diverticulum
…nosis. The coroner identified failures in nursing advocacy, hierarchical communication, and absence of CT scanning at the regional hospital.
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…
63y · Female·Escherichia coli septicaemia in a lady with multiple comorbidities
…ediate antibiotic administration while awaiting blood culture results. She suffered cardiac arrest during scanning and died despite resuscitation. The coroner found that while antibiotics should have been given priority …
53y · Male·metastatic carcinoma of the rectum (operated)
Paul Eugene Anker, a 53-year-old prisoner, died from metastatic rectal carcinoma at the Queen Elizabeth Hospital. He had been appropriately diagnosed with bowel cancer in 2016 whilst in custody and underwent surgery, che…
64y · Male·Complications of redo thoracotomy/aortic valve replacement in a man with ischaem…
… correct, pre-operative investigations were standard, and informed consent was obtained. Pre-operative CT scanning was not standard practice in 2012 and was not required, though expert opinion differed on whether it migh…
72y · Male·cerebral malignancy (glioblastoma multiforme)
…ied three intracerebral lesions. He was promptly transferred to Royal Adelaide Hospital where MRI and PET scanning were conducted to locate a primary cancer. Neuroradiologist review confirmed glioblastoma with very poor …
41y · Male·Subdural haematoma
… fixed pupils); and delayed notification of medical staff about clinical deterioration. Although early CT scanning was limited by rural equipment availability, proper use of early warning tools (Q-ADDS) and escalation pr…
58y · Male·metastatic multiple myeloma
…dical review by a senior medical oncologist concluded that while there was a 2-3 week delay in initial CT scanning in 2004, earlier diagnosis would not have prevented death. The disease was disseminated and advanced at d…
41y · Male·Head Injury in a Man with Acute Alcohol Intoxication; basal skull fracture with …
…ctor who did not recognise the severity of injury, was intimidated by aggressive behaviour, and lacked CT scanning capability for diagnosis. The patient was released to friends despite meeting standard criteria for head …
89y · Male·fractured cervical spine (C5 inferior articular process fracture) due to unwitne…
An 89-year-old man with Parkinson's disease fell at home on 16 August 2016, sustaining a cervical spine fracture. Initial CT imaging missed the C5 inferior articular process fracture, reporting only a paraspinal haematom…
84y · Female·acute left subdural haematoma
…s on anticoagulation who sustain minor head injuries should be referred to hospital for assessment and CT scanning. This case illustrates the particular risk of intracranial bleeding in anticoagulated elderly patients wi…
29y · Male·unascertained
Talha Wahab, a 29-year-old man, was reported missing on 15 September 2015 after failing to return home from work. His vehicle was found at Moomba Park in Fawkner. Despite extensive police search efforts over 17 days invo…
69y · Female·bronchopneumonia complicating intracranial tumour (meningioma with obstructive h…
…reports; and absence of diagnostic verification when Ms Kruger transferred to nursing home care. Early CT scanning in 2006-2007 would almost certainly have detected the meningioma, permitting neurosurgical debulking that…
49y · Male·Complications of craniopharyngioma and pan-hypopituitarism
…died on 28 July 2010. The coroner found no autopsy necessary, with external examination and postmortem CT scanning confirming the cause as complications of craniopharyngioma and pan-hypopituitarism. Significantly, the co…
44y · Male·traumatic subarachnoid haemorrhage and diffuse brain injury sustained in a bicyc…
A 44-year-old experienced cyclist died from traumatic subarachnoid haemorrhage and diffuse brain injury sustained in a bicycle crash on 29 July 2015. The coroner concluded after thorough investigation that Mr Patmore los…
21y · Female·Unascertained
Britt Lapthorne, 21, a university student, died in Dubrovnik, Croatia between 18 September and 6 October 2008. She was last seen alive at Club Fuego nightclub at approximately 3:30am on 18 September 2008 after consuming …
44y · Male·Hypoxic brain injury secondary to heroin and alcohol toxicity
A 44-year-old male died from hypoxic brain injury caused by heroin and alcohol toxicity following an overdose. He had a history of depression, financial difficulties, and prior heroin use. After collapsing at a friend's …
51y · Female·peritoneal sepsis with multiple organ failure due to perforation of bowel by for…
A 51-year-old woman with intellectual disability and schizoaffective disorder died from peritoneal sepsis and multiple organ failure caused by bowel perforation from a wooden stick. The stick entered her body via her vag…
60y · Male·metastatic atrial sarcomatoid tumour
Steve Fesus, aged 60, died in custody at Prince of Wales Hospital from metastatic atrial sarcomatoid tumour. He had been diagnosed with cardiac cancer in 2016, underwent surgery, and was in remission until metastases wer…
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