0y · Unknown·focal ventricular myocarditis and myonecrosis resulting from migration of a Peri…
A 10-month-old boy died from myocarditis and myonecrosis caused by migration of a PICC line into his right ventricle. The line was inserted appropriately under general anaesthetic for IV antibio…
60y · Female·Cardiac tamponade due to ruptured heart due to total parenteral nutrition due to…
A 60-year-old woman died from cardiac tamponade caused by TPN fluid leaking into the pericardium through a PICC line inserted to provide nutrition following bowel surgery. The PICC line was inserted under image intensif…
50y · Male·hepatic encephalopathy secondary to liver cirrhosis with background of hepatitis…
…phalopathy causing confusion and delirium. Despite appropriate medical management including fluid drainage, PICC line insertion for medication delivery, antibiotic treatment for peritonitis, and endoscopic assessment rev…
69y · Female·Inadvertent intravenous administration of oral ciprofloxacin in the setting of a…
… standard syringe instead of the appropriate amber oral dispenser. During medication administration via her PICC line, the medication was transferred to a luer-lock syringe without recognition of the wrong route. The pat…
45y · Female·COVID pneumonia complicated by severe electrolyte abnormalities
…enza, then COVID-19 infection. Difficult venous access due to contractures prevented adequate IV access and PICC line insertion, limiting ability to monitor and replace electrolytes. The team appropriately decided agains…
28y · Male·Mixed drug toxicity (synergistic effects of diazepam, oxycodone, and fentanyl ca…
Matthew McLachlan, a 28-year-old paraplegic with chronic pain from spinal cord injury, died from mixed drug toxicity while hospitalized for urinary tract infection treatment. He was receiving fentanyl patches, oxycodone,…
Toxicity from intravenous caesium, DMSO, and other substances administered as pa…
In May 2005, the Kathi Preston Memorial Health Centre (KPMHC) operated an unproven cancer therapy clinic from Dr B.'s home in Perth, Western Australia, administering intravenous treatment containing caesium, DMSO, and La…
66y · Female·retroperitoneal haemorrhage due to anticoagulation following right cerebrovascul…
A 66-year-old woman died from retroperitoneal haemorrhage following anticoagulation for stroke caused by intra-arterial central venous catheter placement. The catheter was mistakenly inserted into the right carotid arter…
42y · Male·Cardiac arrest following hypoxic ischaemic encephalopathy, likely due to E.coli …
Jarrod Wright, a 42-year-old man admitted with cellulitis, developed sepsis-related acute respiratory distress syndrome (ARDS) requiring ICU care with non-invasive ventilation. Critical failures occurred in managing his …
29y · Female·multi-lobe community acquired pneumonia and respiratory failure
Clare Louise Harrison, a 29-year-old woman with long-standing anorexia nervosa diagnosed at age 17, died from community-acquired pneumonia and respiratory failure after a final 21-day admission to Alice Springs Hospital.…
52y · Female·Mixed drug toxicity (methadone, pregabalin, valproic acid, benzodiazepines)
A 52-year-old woman with chronic pain, epilepsy, and opioid dependence died from mixed drug toxicity after prescribed methadone, pregabalin, valproic acid, and benzodiazepines. She was admitted to Box Hill Hospital on 12…
75y · Male·Burns
75-year-old John Drane, a resident of Masonic Care Queensland, died from extensive burns on 9 January 2014. The coroner concluded he intentionally set himself alight using a cigarette lighter shortly after receiving his …
12y · Male·Cardiac haemorrhage due to or as a consequence of congenital aortic stenosis (su…
Joshua Statis, a 12-year-old with complex congenital aortic stenosis, died 18 days after a redo Konno procedure and aortic valve replacement when a CardioCel patch to the right ventricular outflow tract (RVOT) ruptured, …
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