68y · Female·Haemorrhage secondary to right subclavian artery lacerations sustained during ce…
…d woman died from massive blood loss following inadvertent puncture of the right subclavian artery during central venous line insertion. The anaesthetist used anatomical landmarks without ultrasound after an initial hig…
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 antibiotics …
38y · Male·abdominal and chest sepsis complicating iatrogenic left pneumothorax and laparot…
…emergency surgery. Post-operatively he aspirated, developed aspiration pneumonia and septic shock. During central line insertion for inotrope support, an iatrogenic left pneumotharax occurred. The coroner found the care…
60y · Male·End stage renal failure
… Hospital. He had schizophrenia and chronic kidney disease requiring dialysis, but repeatedly removed his central line (permacath). After a traumatic reinsertion in March 2013 caused cardiac arrest, radiologists advised…
7y · Female·cardiac tamponade due to total parenteral nutrition fluid leakage into the peric…
…cardiac tamponade caused by total parenteral nutrition (TPN) fluid leaking into the pericardial sac via a central venous line inserted during bowel obstruction surgery. Clinical lessons: cardiac tamponade is a rare but …
74y · Female·Complications of carotid artery injury from central line insertion in the settin…
…old woman with metastatic colon cancer, died from complications of carotid artery injury sustained during central venous catheter (CVC) insertion as part of a Whipple procedure and hemicolectomy. The CVC was inadvertent…
62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (su…
… poor outcomes: late recognition of blood loss, delay in activating massive transfusion protocol, loss of central line preventing vasopressor administration, inadequate team communication, and suboptimal fluid resuscita…
63y · Male·Right cerebral infarction caused by infusion of medication via central venous li…
…spiratory depression, hypernatremia and alcohol withdrawal requiring benzodiazepines and BiPap support. A central venous line was inserted for medication access prior to transfer to ICU. The line was inadvertently place…
60y · Female·Cardiac tamponade due to ruptured heart due to total parenteral nutrition due to…
…-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 intensificati…
39y · Male·dilated cardiomyopathy
…put. Despite high-quality medical management by experienced clinicians, he suffered cardiac arrest during central line insertion and could not be revived. The coroner concluded the death resulted from combined chronic c…
38y · Male·Urosepsis
John Miklosowa, a 38-year-old man with Down syndrome and severe intellectual disability, died from urosepsis after rapid deterioration at his residential facility on 28 March 2009. He had a permanent suprapubic catheter …
64y · Male·Postoperative intra-abdominal bleeding from pancreatic artery injury and its con…
John Reginald Beech, 64, died at Sydney Adventist Hospital on 24 April 2007 from postoperative intra-abdominal hemorrhage following colonic surgery. One week earlier, he underwent high anterior resection and hernia repai…
39y · Male·Hypoxic/Ischaemic Encephalopathy due to Cerebral Arterial Gas Embolism
…dday but the device remained in place for 6+ hours while Phillip sat out of bed with family visitors. An IV line disconnected from the Multi Flow Extension Set, allowing air entry into the CVAD. Critical failures include…
66y · Female·retroperitoneal haemorrhage due to anticoagulation following right cerebrovascul…
…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 artery instead of …
48y · Male·sepsis and renal failure due to perforated gastric ulcer
A 48-year-old man with hepatitis C and schizo-affective disorder presented to West Coast District Hospital on 20 October 2014 with severe abdominal pain radiating to the right shoulder tip, generalised tenderness, and a …
49y · Female·Intra-abdominal haemorrhage, septic and haemorrhagic shock as a result of a lapa…
Deborah Burgen died from intra-abdominal haemorrhage complicated by septic shock following delayed emergency surgery for bowel obstruction. She attended the emergency department six times over eleven days with identical …
77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…
… and high-risk comorbidities; (3) ICU consultation should have occurred during weekend deterioration; (4) central venous pressure monitoring would have guided fluid management more accurately; (5) consultant cardiologis…
30y · Male·Acute pneumonia and multi-organ failure, due to or as a consequence of traumatic…
Faysal Ishak Ahmed, a 30-year-old Sudanese refugee, died from traumatic brain injury sustained in a fall down stairs at Manus Island Regional Processing Centre on 22 December 2016. He collapsed and fell while alone, like…
57y · Male·Multiple Organ Failure and Intra-Abdominal Haemorrhage following Cholecystectomy
A 57-year-old man with multiple comorbidities (obesity, diabetes, hypertension, COAD, sleep apnoea) underwent elective laparoscopic cholecystectomy at a regional hospital. The procedure was converted to open due to dense…
36y · Male·Multiple injuries sustained from intentional jump from cliff top
Alexander Albert Steinbrenner, a 36-year-old man with schizo-affective disorder, died from multiple injuries sustained when he jumped from an 11-metre cliff at the Roundhouse in Fremantle on 27 February 2004. He was an i…
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