80y · Male·asphyxia due to choking on food
Robert Mather, 80, died from asphyxia due to choking on food while hospitalised with acute psychosis, severe malnutrition, iron deficiency anaemia and urinary retention. He had schizophrenia with 4…
84y · Male·Complications of gout and old spinal injury, cause unknown
…pinal cord injury, renal impairment, cardiac failure) presented with chest infection, abdominal pain, and urinary retention. He was treated with intravenous antibiotics for suspected overwhelming sepsis. Despite appropr…
63y · Female·Aspiration of gastric contents and acute renal failure complicating intestinal p…
…ilepsy treated with carbamazepine, and chronic hyponatraemia, died from aspiration of gastric contents and acute renal failure complicating intestinal pseudo-obstruction. She presented with acute hyponatraemia and confu…
96y · Male·general inanition on a background of advanced dementia, chronic congestive cardi…
…, chronic congestive cardiac failure and pneumonia at Repatriation General Hospital. He was admitted with urinary retention, acute renal failure, delirium and pneumonia. During his admission he experienced multiple fall…
64y · Male·Large pulmonary embolus (origin undetermined)
…on District Hospital following a complex admission involving psychiatric depression, atrial fibrillation, urinary retention, and multiple comorbidities. The coroner identified significant system failures: warfarin was r…
58y · Male·complications of large bowel pseudo-obstruction
…ry, with minimal documentation and no appreciation of his high-risk status. No consideration was given to urinary retention (present on imaging), repeat imaging to confirm improvement, or operative intervention. Key cli…
52y · Female·Renal Failure Complicating Urosepsis in a Woman with Down Syndrome (Palliated)
…syndrome, chronic renal failure, and requiring permanent catheterisation, developed urosepsis following a urinary tract infection. She presented with back pain, fever, and hypotension on 9 May 2012, was seen by locum do…
33y · Male·Marburg variant of multiple sclerosis
…om Marburg variant multiple sclerosis after rapid neurological deterioration. He initially presented with urinary retention on 1 December 2022, which was appropriately investigated. When acute neurological symptoms emer…
67y · Male·Acute on chronic renal failure with pyelonephritis
William Heale, a 67-year-old man with Down syndrome and chronic renal failure, died from acute-on-chronic renal failure complicated by pyelonephritis. He was initially managed in the community with sup…
58y · Female·Enterococcus faecalis sepsis and acute renal failure
…-year-old woman with intellectual disability and schizophrenia, died from enterococcus faecalis sepsis and acute renal failure on 7 August 2009. She presented to Angliss Hospital ED on 31 July with urinary retention pos…
51y · Male·metastatic small round cell malignancy (Ewing's Sarcoma)
…tis C, died from metastatic small round cell tumour (Ewing's Sarcoma) while in custody. He presented with urinary retention and lower limb weakness in January 2018, underwent urgent spinal decompression surgery, and was…
86y · Male·Septic shock secondary to urosepsis
…s or the ordered blood tests before discharge. Avery was readmitted next day with sepsis from a resistant urinary tract infection and died of septic shock. Key failures included: failure to review progress notes and blo…
64y · Male·necrotising fasciitis precipitated by a fishbone perforating his rectum, leading…
…radiographic evidence of intra-abdominal pathology, a first-year registrar (Dr C.) attributed symptoms to urinary retention and referred to urology rather than urgently consulting his supervisor. The coroner found this …
54y · Male·Unascertained
A 54-year-old man with HIV, hepatitis C, cirrhosis, and significant immunocompromise presented with acute sepsis on 23 December 2016. Despite rapid ambulance response with sepsis protocol initiation and ICU-level…
76y · Male·Streptococcus pneumoniae sepsis in the setting of acute bronchopneumonia and ren…
…year-old man with dementia, vascular disease, and depression, died of streptococcal pneumoniae sepsis with acute bronchopneumonia and renal failure from obstructive uropathy at an aged care facility. Key clinical lesson…
75y · Female·pyelonephritis and pneumonia
…ection presenting as fever, tachycardia, tachypnoea and other vital sign abnormalities. He misdiagnosed a urinary tract infection progressing to kidney infection as a chest infection and prescribed only oral antibiotics…
86y · Male·pulmonary embolism following deep vein thrombosis
…order following a relapse of psychotic depression at his aged care facility. Clinical examination found no acute cause for his mental deterioration. He was medically cleared for admission to the psychiatric ward. Post-a…
72y · Female·haemorrhage from penetrating duodenal ulcer
A 72-year-old woman collapsed at home and was admitted with black bowel motions (melaena) suggestive of gastrointestinal bleeding. This crucial history was documented by the ED doctor but not properly acted upon by the a…
58y · Male·Pneumonia and urosepsis
Brent Newman, a 58-year-old man with Down syndrome and early-onset dementia, died from pneumonia and urosepsis following inadequate care at an aged care facility. His indwelling catheter was poorly managed, causing ureth…
46y · Male·sepsis following haemorrhoidectomy
… overnight but deteriorated significantly from 11:00 am on 18 July, showing hypotension, tachycardia, and urinary retention. Clinical and laboratory clues of early sepsis—raised creatinine and urea, elevated heart rate …
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