31y · Female·right cerebellar cerebrovascular accident (cerebellar infarction with obstructiv…
…sment occurred until next morning. The patient had actually suffered vertebral artery dissection causing cerebellar infarction. By Sunday she developed catastrophic cerebellar edema with obstructive hydrocephalus and her…
42y · Female·multiorgan failure complicating hyperthermia and metabolic acidosis following su…
…ageal perforation, mediastinitis, acute kidney injury, septic shock), she developed cerebral oedema with herniation and died on 15 May 2019. The coroner found her care was appropriate and attentive. Key clinical lessons …
78y · Female·Complications of a left tentorial meningioma
…he died suddenly on 10 September 2015 from complications of the meningioma (intratumoral haemorrhage and herniation) before surgery could be performed. The coroner found neurosurgical management appropriate but identifie…
30y · Male·Heroin overdose
…se) and the deceased was on a Community Treatment Order. Dr L. wrote a complex death certificate listing cerebellar tonsillar herniation, cerebral oedema, hypoxic brain injury, and respiratory arrest due to heroin overdo…
3y · Male·Brainstem ischaemia in association with Arnold Chiari malformation
Matthew Whyte, a 3-year-old with Arnold Chiari malformation and hydrocephalus, died from brainstem ischaemia following multiple shunt complications and emergency decompression surgery. The coroner found that after Matthe…
31y · Female·raised intracranial pressure due to ventriculoperitoneal shunt dysfunction (disc…
Emilie Le Coz, aged 31, died from raised intracranial pressure secondary to ventriculoperitoneal shunt disconnection. She presented to hospital in March 2010 with progressive headaches, cognitive changes and behaviour de…
1y · Male·acute meningitis from Streptococcus pneumoniae, associated with diffuse brain sw…
Noah Souvatzis, a 19-month-old boy, died from Streptococcus pneumoniae meningitis on 31 December 2021 after presenting to Northeast Health Wangaratta ED on 29 December. Critical failures in his first ED presentation incl…
4y · Male·Complications of T-cell lymphoma
Nghi Pham was a 4-year-old admitted to Sunshine Hospital with facial swelling, stridor, and upper respiratory symptoms. He was examined by emergency and ENT teams, diagnosed with adenoiditis and sinusitis, and discharged…
15y · Male·Multiple organ failure associated with hyperthermia (heat stroke)
A 15-year-old rugby league player died from heat stroke during training on an extremely hot Perth summer evening (44.4°C). The coaching staff appropriately applied NRL heat guidelines in deciding to proceed with modified…
11y · Male·Sepsis
An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…
43y · Male·Hypoxic ischaemic encephalopathy, due to or as consequence of, cardiac arrest of…
A 43-year-old man with methamphetamine toxicity was restrained by police and given two doses of droperidol by paramedics who failed to recognize he was critically unwell. The first dose was clinically indicated, but the …
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