67y · Male·Gas gangrene with antecedent cause of Clostridium septicum septicaemia
… pain management and initial investigation suggesting rhabdomyolysis, he rapidly deteriorated and died from gas gangrene caused by Clostridium septicum. While the coroner found no material deficiencies in clinical care,…
54y · Female·complications related to post-polio syndrome and chronic respiratory weakness; n…
…ith post-polio syndrome during respiratory transition periods, the importance of completing physiological testing during ventilator changes, and awareness of medication-alcohol interactions in patients with compromised …
70y · Female·Cardiac arrest caused by a combination of gastric haemorrhage and pneumonia exac…
Mrs Kathleen Anne Conlan, 70, died from cardiac arrest caused by gastric haemorrhage and pneumonia on a background of coronary artery disease. She presented with severe epigast…
2y · Male·Perinatal asphyxia leading to cerebral anoxia and subsequent multi-organ failure
…old. Critical clinical lessons emerged regarding neonatal assessment: persistently pale newborns with cord blood pH 7.02 and hypothermia require investigation for anaemia and foetal-maternal haemorrhage, and repeat bloo…
Jessica: disseminated intravascular coagulation following haemorrhage (subgaleal…
…th deliveries were technically appropriate. Jessica's death may have been preventable: she required urgent blood transfusion which was ordered but not delivered before her collapse—Dr B. did not adequately follow up on …
11y · Male·Sepsis
…osseous or intramuscular administration, and communication breakdown (junior registrar unaware of critical blood gas results showing acidosis and elevated lactate). The coroner found this delay in treatment was not appr…
56y · Female·pulmonary thromboembolism due to left calf deep vein thrombosis
…surgery. On 13 July, an intern noted oxygen saturation of 95% on supplemental oxygen and obtained arterial blood gas tests showing hypoxia, raising concern for pulmonary embolism. However, the registrar was not informed…
2y · Male·Group A beta Haemolytic Streptococcal septicaemia (invasive Group A Streptococca…
…rm the tachycardia; failure to examine and reassess after petechial rash appeared; and not taking baseline blood pressure until 8pm. Although antibiotics were eventually ordered at 8.30pm, there was a two-hour delay bef…
82y · Male·respiratory failure
Ronald William Barnard, an 82-year-old male prisoner, died from respiratory failure following a three-day illness. He presented to hospital on 20 January with shortness of breath and chest pain, was diagnosed with pneumo…
78y · Male·cardiorespiratory failure due to complications of tracheal stenosis
…irway narrowing warranted closer monitoring and potentially transfer to higher-level care; (4) An arterial blood gas test should have been performed to assess carbon dioxide retention; (5) Specialist review by respirato…
0y · Female·acute blood loss due to velamentous insertion of the umbilical cord with likely …
A neonate died from acute blood loss due to velamentous insertion of the umbilical cord with likely vasa previa, a rare condition causing …
31y · Male·Pulmonary thromboembolism arising from deep vein thrombosis
…eteriorated rapidly in hospital and died despite thrombolytic therapy. The coroner found that preliminary testing (D-dimer or ultrasound) for DVT in December would likely have been diagnostic and allowed anticoagulation…
64y · Male·Complications of metformin toxicity on a background of undiagnosed renal impairm…
…gnition of severe metabolic derangement; incomplete vital sign documentation; failure to perform troponin testing; and delayed physician attendance. RN Magazini did not call an ambulance when indicated by guidelines des…
16y · Female·acute abdominal obstruction secondary to adhesions associated with severe pelvic…
…her second presentation on 24 December, she was discharged home without a clear diagnosis despite abnormal blood tests (elevated white cell count, raised inflammatory markers, metabolic acidosis) suggestive of possible …
28y · Female·3,4-methylenedioxy-N-methylamphetamine (MDMA) and ketamine toxicity
Trang Thi Thu Le, 28, died on her birthday from MDMA and ketamine toxicity after attending an electronic dance music event at John Cain Arena. She collapsed after consuming drugs purchased from an unknown source within t…
82y · Female·Hyperkalaemia due to acute renal failure on a background of end stage pulmonary …
An 82-year-old woman with terminal pulmonary fibrosis and chronic respiratory failure presented with chest pain, hyperkalaemia and metabolic acidosis. She became combative and was given haloperidol and morphine for agita…
58y · Male·Respiratory failure due to or as a consequence of Chronic Obstructive Pulmonary …
Geoffrey Hornby, a 58-year-old prisoner with significant COPD, ischemic heart disease, and multiple comorbidities, died from respiratory failure secondary to COPD. He was admitted to hospital with COPD exacerbation and d…
5y · Female·myocarditis
A five-year-old girl died from fulminant myocarditis caused by influenza A on 5 July 2022 at Canberra Hospital. The diagnosis was delayed over 7 hours from initial presentation. Critical failures included: ED triage Cate…
16y · Male·pulmonary embolism secondary to nephrotic syndrome
Dylan Riley, a 16-year-old with steroid-responsive minimal change nephrotic syndrome, died from a massive pulmonary embolism (PE) on 1 August 2015. He presented to Rockingham Hospital with dyspnoea, hypoxia, tachycardia …
Unknown·Ms Fensom: influenza A (H1N1 2009, pandemic swine flu) with myocarditis causing …
…g on 18 August, but the treating registrar (Dr V.) failed to recognise the seriousness of persistently low blood pressure despite it not responding to fluid therapy. Mr Taankink (26), an asthmatic, was prescribed Tamifl…
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