55y · Male·cardiac tamponade resulting from proximal aortic dissection due to hypertension
…evere chest pain, headache and jaw pain to a regional hospital was evaluated for aortic dissection. A CT angiogram was performed but the radiologist's verbal report contained ambiguities and omissions compared to the wr…
69y · Male·subarachnoid haemorrhage with contributing cardiomegaly
…vere headache, photophobia, nausea and neck stiffness—classic features of subarachnoid haemorrhage. A CT angiogram identified a 6mm aneurysm on the anterior communicating artery. The general practitioner sent a detailed…
62y · Male·Extensive liver tumour, primary site not identified
James Williams, a 62-year-old man with intellectual disability, presented to his GP with tiredness, anorexia and fever. Initial assessment suggested possible hepatitis and he was referred to hospital. CT imaging revealed…
81y · Male·Head injury sustained in a fall
…om a head injury sustained in a fall on 20 December 2019, with death occurring on 24 December 2019. A CT angiogram at 3:45pm showed worsening intraventricular haemorrhage (IVH) that was not identified by the neurology c…
51y · Male·Multiorgan failure in a man with corrected congenital coarctation of the aorta a…
Sean Raymond Adams, 51-year-old male with complex cardiac history including corrected coarctation of aorta, valvular disease, and biventricular heart failure, presented to Alfred Hospital ED with chest pain and dyspnoea.…
63y · Male·pneumonia complicating anoxic brain injury, due to post-operative haemorrhage as…
…ns of hypovolaemic shock (hypotension, tachycardia, sweating, dyspnoea) were not recognised as requiring emergency intervention. The junior registrar (Dr T.) inappropriately delegated care to a first-year intern (Dr K.)…
73y · Male·sepsis due to ischemic gut due to occlusion of the superior mesenteric artery
…sented with acute severe abdominal pain caused by superior mesenteric artery (SMA) occlusion. Initial CT angiogram at 12:30am was reported as normal; the SMA occlusion was not identified until 4:45am—over 4 hours later—…
83y·cardiac tamponade due to haemopericardium resulting from traumatic parietal peri…
…resented to the ED with chest pain and was found to have a pericardial effusion. She underwent an aortic angiogram but critical investigations including echocardiography were not clearly documented. A pericardiocentesis…
52y · Male·ischaemic heart disease
Hassan Bechara, a 52-year-old prisoner, died from ischaemic heart disease in July 2017. He had complex cardiac history including dilated cardiomyopathy, triple-vessel coronary disease, and previous cardiac procedures. Cl…
79y · Male·myocardial infarction
A 79-year-old man with significant comorbidities (ischaemic heart disease, diabetes, peripheral vascular disease) was admitted to hospital with anorexia and weight loss. He developed acute confusion and delirium, initial…
63y · Male·Cerebral infarction complicating vertebral artery dissection following motor veh…
…ging at 10:44am identified significant cervical spine injuries, but critical imaging results (MRI and CT angiogram) were delayed approximately 4.5 hours. The patient deteriorated acutely around 5:15pm during further ima…
60y · Male·haemopericardium due to rupture of right ventricle complicating removal of cardi…
…e (situated 100 metres away), leading to a 20-25 minute diagnostic delay while an unproductive pulmonary angiogram was performed instead. The coroner found that had diagnostic ultrasound been immediately available, the …
46y · Male·Pulmonary thromboembolism complicating left calf deep venous thrombosis
…o-day history of left calf pain, swelling and numbness. He was triaged to Fast Track and evaluated by an emergency physician who suspected DVT but had no ultrasound available on Boxing Day. He was discharged with Clexan…
76y · Male·Extensive small bowel infarction caused by superior mesenteric artery thrombus
…c ischaemia—characterised by severe pain without significant clinical signs—was not diagnosed until a CT angiogram performed 19 hours post-presentation revealed superior mesenteric artery thrombosis with acute bowel isc…
57y · Male·hypoxic ischaemic brain injury complicating acute asthma
A 57-year-old man with asthma and hay fever died from hypoxic ischaemic brain injury following an acute asthma exacerbation during Melbourne's November 2016 thunderstorm asthma event. The deceased was outdoors during the…
71y · Female·aortic dissection (Stanford Type A)
…erlying cause was a Stanford Type A aortic dissection, which was not identified during life despite a CT angiogram being performed. The CT images were suboptimal due to poor cardiac output and could not adequately exclu…
53y · Male·Bilateral ACA stroke
A 53-year-old man presented to the emergency department with acute stroke symptoms (left-sided hemiplegia and dysphasia) with onset around 10:30 am. …
42y · Female·Subarachnoid haemorrhage as a consequence of rupture of saccular aneurysm of the…
…gnosed anterior communicating artery aneurysm causing subarachnoid haemorrhage. She received appropriate emergency medical care with timely Code Blue response and resuscitation by nursing staff, followed by paramedic tr…
69y · Male·thoracic aortic aneurysm with dissection
…ented to Calvary Hospital on 19 August 2021 with sudden chest discomfort and neurological symptoms. A CT angiogram was performed but the radiologist, Dr CD, failed to identify the aortic dissection, instead reporting on…
70y · Male·Complications of Ischaemic cardiomyopathy and Chronic Obstructive Pulmonary Dise…
Stephen Pitty, aged 70, died from complications of ischaemic cardiomyopathy and chronic obstructive pulmonary disease whilst in custody at Long Bay Correctional Centre. He had significant cardiac history including seven …
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