87y · Male·multi organ failure due to septic shock complicating urinary tract infection and…
…l fibrillation on warfarin developed septic shock and multi-organ failure following traumatic bladder catheterisation. Two catheterisation attempts occurred on 15 July 2005: an unsuccessful attempt by an RDNS nurse foll…
52y · Female·Renal Failure Complicating Urosepsis in a Woman with Down Syndrome (Palliated)
…Isabell Mills, a 52-year-old woman with Down syndrome, chronic renal failure, and requiring permanent catheterisation, developed urosepsis following a urinary tract infection. She presented with back pain, fever, and hy…
61y · Male·urosepsis in the setting of chronic suprapubic catheterisation in a man with con…
Wayne Daniel Holland, aged 61, died from urosepsis related to chronic suprapubic catheterisation. He had significant disability from congenital rubella and lived in specialist disability accommodati…
96y · Male·hospital acquired pneumonia on a background of advanced Alzheimer's dementia
… due to behavioural concerns. During his 8-day admission, he developed urinary retention managed with catheterisation, pneumonia identified on chest X-ray, and subsequently renal failure despite antibiotic treatment. Hi…
59y · Female·acute cardiogenic shock, with acute mechanical obstruction of a remote mechanica…
Ida Romeo, 59, died during cardiac catheterisation at Liverpool Hospital when a pressure wire became trapped in her mechanical aortic valve. She had con…
80y · Male·inanition complicating end stage dementia
…g hospitalisation he experienced multiple medical complications including urinary retention requiring catheterisation, swallowing difficulties, and a pulmonary embolism. A palliative approach was appropriately adopted f…
51y · Male·Multiorgan failure in a man with corrected congenital coarctation of the aorta a…
…th chest pain and dyspnoea. He was diagnosed with NSTEMI and admitted. During preparation for cardiac catheterisation, he developed acute deterioration and suffered cardiac arrest. Resuscitation was undertaken following…
60y · Female·haemopericardium following thoracic aortic dissection Type A
…G was obtained but not appropriately interpreted. She had minimal urine output over 7.5 hours despite catheterisation. Doctors discharged her at 4 am with provisional diagnosis of infection, missing signs of acute aorti…
75y · Male·Multi-organ failure due to sepsis secondary to hospital-acquired pneumonia
A 75-year-old man with Alzheimer's dementia who was detained under Mental Health Act orders died from multi-organ failure due to sepsis secondary to hospital-acquired pneumonia. He was admitted to Royal Adelaide Hospital…
31y · Male·sepsis due to urosepsis and pneumonia on a background of C3 incomplete tetrapleg…
…te medical care in custody. The death was attributed to complications of long-term indwelling bladder catheterisation, a known risk factor for sepsis in spinal cord injury patients. The expert specifically commended Pri…
87y · Male·aspiration pneumonia, urinary tract infection and general inanition complicating…
…plications including urinary retention and pneumonia. He required escalating levels of care including catheterisation, restraints (mittens), and eventually palliative care. The coroner found the care provided during the…
52y · Female·laceration of the superior vena cava and right atrium during defibrillator lead …
A 52-year-old woman with a history of syncope and mitral valve prolapse, who had an implanted defibrillator, underwent a percutaneous laser lead extraction procedure at Westmead Hospital to remove and replace defective l…
0y · Male·Scimitar syndrome
…nary hypertension. The infant received intensive care at Princess Margaret Hospital including cardiac catheterisation and emergency surgery. The coroner found that care provided by both the paediatric cardiology and int…
51y · Male·complications of myocardial infarction in association with ischaemic heart disea…
…chest pain and low oxygen saturation (89%), was appropriately sent to hospital, and underwent cardiac catheterisation with stent placement. He suffered cardiac arrests on 4 and 5 February and died despite resuscitation.…
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 vulnerability to catastrophic bleeding. Key clinical lessons include: (1) prenatal…
60y · Male·Ischaemic gut secondary to superior mesenteric artery dissection complicating in…
A 60-year-old man with severe coronary artery disease presented with acute myocardial infarction, requiring emergency stenting and subsequent bypass surgery. An intra-aortic balloon pump (IABP) was inserted for haemodyna…
96y · Male·general inanition on a background of advanced dementia, chronic congestive cardi…
Colin Pryor Tucker, aged 96, died of general inanition on a background of advanced dementia, chronic congestive cardiac failure and pneumonia at Repatriation General Hospital. He was admitted with urinary retention, acut…
86y · Male·Sepsis with septic shock, due to urinary tract infection, pyelonephritis (kidney…
…to urinary retention, infection of retained urine, and fatal sepsis. Timely urological assessment and catheterisation or surgery would likely have prevented death. Critical failures included: incomplete history-taking, …
86y · Male·multi-organ failure due to sepsis on a background of sacral pressure ulcer
An 86-year-old man died from multi-organ failure due to sepsis from a stage 4 sacral pressure ulcer after 61 days in a regional hospital. Critical failures included delayed pressure injury risk assessment (7 days overdue…
3y · Female·Complications resulting from progressive right ventricular failure as a conseque…
Debbie Anne Douglas, a 3-year-old Aboriginal girl with DiGeorge syndrome and complex congenital heart disease, died from progressive right ventricular failure. She had been in state care since August 2003 due to parents'…
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