55y · Male·cardiac tamponade resulting from proximal aortic dissection due to hypertension
…s documented 'no dissection' despite the written report not definitively excluding it. A transthoracic echocardiogram ordered by cardiology was cancelled the next day due to an administrative error, delaying diagnosis by…
53y · Male·Acute myocardial infarction due to triple vessel atherosclerosis and thrombosis …
…made, and an exercise stress test (November 2022) showed equivocal results suggestive of ischaemia. An echocardiogram in February 2023 revealed abnormal left ventricular wall motion indicating coronary artery disease. Ho…
43y · Male·Complications of valvular heart disease
…ual disability and schizophrenia, died from complications of aortic valve stenosis. A transoesophageal echocardiogram in June 2022 demonstrated severe aortic stenosis requiring valve replacement. No follow-up appointment…
14y · Male·ventricular arrhythmia on a background of congenital aortic valve disease
…(1) advise cessation of strenuous physical activity pending surgery, and (2) ensure the September 2014 echocardiogram report reached the Melbourne surgical team—a letter sent in December 2013 also never arrived. Had the …
10y · Male·Unascertained - sudden and unexpected death; evidence did not allow determinatio…
… transient neurological symptoms in April-May 2011 that prompted investigation including ECG, MRI, and echocardiogram, but no definitive diagnosis was established. An EEG was recommended but not completed before his deat…
70y · Male·dilated cardiomyopathy with emphysema as a contributing factor
…ng history. Arrested in April 2018 on serious charges, he received ongoing medical care in custody. An echocardiogram in July 2018 confirmed end-stage heart failure. He was transferred to Royal Hobart Hospital on 16 Sept…
83y·cardiac tamponade due to haemopericardium resulting from traumatic parietal peri…
…e leading to cardiac tamponade and death. Critical deficiencies in medical documentation—missing ECGs, echocardiogram reports, and procedure notes—severely hampered investigation. Standard practice dictates pericardiocen…
62y · Male·chronic congestive cardiac failure due to severe aortic valve stenosis and incom…
…coming symptomatic in 2008. A critical missed opportunity occurred in August 2008 when Hunt refused an echocardiogram appointment, with inadequate documentation of reasons for refusal. In January 2010, cardiology assessm…
44y · Male·Ischaemic heart disease due to coronary atherosclerosis
…for possible cardiac pathology. Despite investigation including chest X-ray, abdominal ultrasound, and echocardiogram (all reportedly normal), the underlying coronary artery disease was not identified. He self-ceased pre…
28y · Female·hypoxic brain injury following cardiac arrest in association with pulmonary hype…
…further investigations ordered; (4) two weeks later, Dr B. identified severe pulmonary hypertension on echocardiogram but lacked clinical context, and neither she nor Dr U. conveyed appropriate urgency to the patient. Th…
51y · Male·combined effects of dilated cardiomyopathy with myocardial fibrosis and prescrip…
Jacob MacDonald, 51, died at the Forensic Hospital from combined effects of dilated cardiomyopathy with myocardial fibrosis and toxic levels of clozapine and aripiprazole. He was an involuntary forensic psychiatric patie…
44y · Female·Ischemic heart disease due to complete blockage of left anterior descending coro…
A 44-year-old woman presented with acute chest pain and troponin elevation. Coronary angiography revealed only a 30% non-obstructive lesion in the left anterior descending artery. She was discharged on aspirin alone with…
35y · Male·intraperitoneal haemorrhage from an anastomotic leak from a transplanted renal a…
Luke Wood, a 35-year-old kidney transplant recipient, died 11 days post-transplant from intraperitoneal haemorrhage due to anastomotic leak from the transplanted renal artery. While post-operative inpatient care and init…
85y · Male·Sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left …
An 85-year-old man died in custody from sepsis due to Staphylococcus aureus bacteraemia arising from septic arthritis of the left shoulder, on a background of congestive heart failure. While receiving generally adequate …
68y · Male·Cardiomegaly
…izophrenia, and intellectual disability, died suddenly from cardiomegaly while in residential care. An echocardiogram performed shortly before death showed severe worsening of his cardiac function with very poor ejection…
72y · Male·ischaemic heart disease
…ied of ischaemic heart disease. He was under regular management by his GP who had recently arranged an echocardiogram. The patient reported atypical chest pain at his last consultation one week before death. He collapsed…
77y · Female·combined effects of ischaemic heart disease and calcific aortic valve sclerosis
…CG was abnormal but a cardiology registrar advised deferring troponin testing and arranging outpatient echocardiogram rather than urgent transfer to Royal Hobart Hospital's cardiac unit. She was discharged, collapsed aga…
27y · Male·Cause of death cannot be determined; most likely cardiac arrhythmia in the setti…
… community mental health monitoring including regular appointments, medication administration, and ECG/echocardiogram surveillance. After initial non-compliance post-discharge, he re-engaged with treatment by late Novemb…
7y · Female·cardiac tamponade due to total parenteral nutrition fluid leakage into the peric…
…e BP, faint pulses, and cool peripheries—especially after 12:25 AM—might have prompted urgent imaging (echocardiogram) and cardiology consultation. Enhanced training on central line complications, awareness of decompensa…
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…
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