5y · Female·myocarditis
…nsultant paediatrician; lack of allocated responsibility for following up troponin test results; failure of ICU to properly assess the critically ill child despite consultation; inadequate handover processes with siloed…
72y · Female·probable sepsis complicating chemotherapy for non-Hodgkin's lymphoma
…L), and signs of shock. The surgical team failed to recognize evolving septic shock and did not escalate to ICU until 7:10pm, when her condition had critically deteriorated. By 1:00pm, vital signs clearly indicated sept…
77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…
… earlier; (2) senior clinician review warranted overnight given complexity and high-risk comorbidities; (3) ICU consultation should have occurred during weekend deterioration; (4) central venous pressure monitoring woul…
43y · Female·Hypoxic ischaemic brain injury resulting from alcohol and sodium valproate toxic…
…r instability, metabolic acidosis). Early intubation at PDH, prompt senior escalation, early toxicology consultation, and timely dialysis at WBH could have prevented death. Systemic issues included VPIC staffing shortage…
81y · Female·Severe cardiogenic shock complicating cardiac surgery
…ortic valve replacement complicated by intraoperative haemodynamic instability and inadequate postoperative ICU management. The surgery involved emergency coronary artery bypass grafting and was technically sound, but a…
66y · Female·retroperitoneal haemorrhage due to anticoagulation following right cerebrovascul…
…onsultant input and delayed diagnosis. A four-hour gap occurred between diagnosis of haemorrhagic shock and ICU review. The coroner found the death almost certainly preventable, highlighting serious deficiencies in MET …
79y · Female·cardiogenic shock following repair of fractured right femur on a background of a…
… was admitted with a fractured right femur. Post-operatively she developed acute pulmonary oedema requiring ICU admission. Cardiology identified myocardial ischaemia; an angiogram was discussed but her condition deterio…
51y · Male·Spontaneous intracerebral haemorrhage
…le, causing him to crash. He was transported to Alice Springs Hospital where he remained on life support in ICU for one week before dying. Autopsy confirmed spontaneous right intracerebral haemorrhage with secondary bra…
33y · Female·Hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiop…
…Expert review identified multiple clinical and systemic failures: inadequate micronutrient replacement (particularly thiamine), unappreciated gross fluid and sodium overload despite evident signs including pulmonary oed…
61y · Male·Ischaemic heart disease in the setting of aspiration pneumonia in a man with Pra…
…g, loose stools and cough, was diagnosed with aspiration pneumonia, deteriorated with hypotension requiring ICU admission for circulatory support. Despite noradrenaline and milrinone, he developed a new right bundle bra…
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
…ailure to place arterial line for continuous blood pressure monitoring; and critically, failure to admit to ICU despite severe sepsis with lactic acidosis, hypotension (<90mmHg systolic for 3 hours), and MEWS scores >9.…
21y · Male·cardiac arrest caused by acute bilateral pneumonia
…lowing wisdom tooth extraction complicated by ventilator-acquired pneumonia. Although discharged early from ICU after 3 days, he developed bilateral acute pneumonia with septicaemia and died at home that evening. The co…
80y · Male·acute myocardial ischaemia due to coronary atherosclerosis
Mr Wade, aged 80, died from acute myocardial infarction following knee surgery. On postoperative day 3, he developed chest symptoms, elevated troponin, and hypoxia. An ECG was performed showing acute anterior myocardial …
18y · Female·Colchicine toxicity
…ich now recommend charcoal for all intentional colchicine ingestions >0.1mg/kg and mandatory toxicology consultation, recognising death can occur at doses below 0.5mg/kg.
49y · Female·Intra-abdominal haemorrhage, septic and haemorrhagic shock as a result of a lapa…
…e to recognise and treat internal bleeding despite clear clinical signs; and poor medical leadership in the ICU with inexperienced overseas-trained doctors in senior positions without proper orientation or supervision. …
50y · Female·Aspiration pneumonia
…ation. After initial extubation and rapid reintubation, end-of-life care was initiated following family consultation. She died from aspiration pneumonia. The coroner found that care and treatment were reasonable and appr…
45y · Female·Pneumonia complicating cerebral palsy and epilepsy
…atory failure. She deteriorated further despite intravenous antibiotics and was managed palliatively in consultation with ICU staff and family before dying on 1 January 2011. The coroner found her death was from natural …
37y · Male·primary intracerebral haemorrhage, contributed to by acute alcohol intoxication
Eric Gaykamangu, a 37-year-old Aboriginal man, died of primary intracerebral haemorrhage whilst in hospital ICU, nine days after initial presentation. He was found intoxicated outside Centrelink on 7 December 2001 with …
8y · Male·Septic shock consequent on burst appendix with peritonitis
…septic peritonitis indicators. Post-operatively, Jacob was inappropriately monitored on the ward instead of ICU despite obvious septic shock. He deteriorated and died during emergency surgery. Multiple clinicians failed…
56y · Female·pulmonary thromboembolism due to left calf deep vein thrombosis
…r was not informed of the initial abnormal ABG result, and a subsequent ABG on oxygen appeared improved. An ICU registrar consulted informally only saw the second ABG result and advised against further investigation. No…
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