64y · Male·Heart failure secondary to alcohol related liver disease, coronary obstructive p…
…o self-discharge against medical advice despite being very unwell with impaired decision-making capacity (hepatic encephalopathy/delirium). An Inpatient Treatment Order was appropriately placed and confirmed by psychiat…
73y · Male·Complications, including multi-organ failure and pneumonia, of chronic obstructi…
Alexander Robert Eatts, a 73-year-old prisoner with severe chronic obstructive pulmonary disease (COPD), congestive cardiac failure, and multiple comorbidities, died from complications of COPD including multi-organ failu…
62y · Male·hepatic encephalopathy due to acute renal failure
Ronnie Pangata Nelson, a 62-year-old Aboriginal man, died in Alice Springs Hospital from hepatic encephalopathy due to acute renal failure. He had longstanding chronic diseases including cirrhosis, hepa…
5y · Female·disseminated candidiasis secondary to protein-energy malnutrition
… but parents delayed seeking medical attention until December 16, when she presented in septic shock with hepatic dysfunction and renal failure. Transfer to Royal Children's Hospital for intensive care with mechanical v…
58y · Female·pneumonia, likely aspiration pneumonia
Mary Marguerite Dickinson, aged 58, died of pneumonia on 20 January 2018 at the Roy Fagan Centre after admission with a complex scapula fracture and severe cognitive decline from alcoholic dementia. The coroner found her…
2y · Male·multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndro…
A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poo…
44y · Male·cardiac arrhythmia in a man with liver failure due to cirrhosis and focal corona…
…ceiving aggressive treatment for his advanced liver disease, which was complicated by cardiac failure and hepatic encephalopathy. The coroner found the death resulted from natural causes and that the quality of supervis…
17y · Female·raised intracranial pressure due to hepatic encephalopathy related cerebral oede…
Jacqueline Wood, aged 17, died from hepatic encephalopathy-related cerebral oedema following fulminant liver failure caused by paracetamol overdose. …
74y · Male·Acute myocardial infarction complicated by multiple organ failure
Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…
80y · Male·metastatic hepatocellular carcinoma
Cemil Guler, an 80-year-old man, died from metastatic hepatocellular carcinoma at Braeside Hospital. He was a forensic patient under Mental Health Act detention after being found not guilty by reason of mental illness of…
64y · Male·Complications of congestive cardiac failure on a background of cardiac hypertrop…
QBT, a 64-year-old man with complex medical and psychiatric history including schizophrenia, COPD, and hypertension, was admitted to Bendigo Hospital on an Assessment Order after police concerns about mental health deter…
51y · Male·unascertained; presumed sudden cardiac arrhythmia
Kenneth Stephens, a 51-year-old man with schizoaffective disorder, died from an unascertained cause while under involuntary psychiatric care. He presented with acute behavioural changes including excessive drinking, unus…
76y · Female·hospital acquired pneumonia, multiple organ dysfunction and small bowel obstruct…
Mrs Cook, a 76-year-old woman, died in January 2010 from hospital-acquired pneumonia, multiple organ dysfunction, and small bowel obstruction. She was admitted to a rural hospital with acute renal failure and dangero…
10y · Female·Multi-organ failure secondary to overwhelming herpes simplex virus (HSV) infecti…
… by two other doctors who also did not consider HSV. By Friday (day 5), blood tests showed severe liver dysfunction and dehydration but were not acted upon appropriately. Critical failures included: not including HSV in…
66y · Female·Multi-organ failure associated with haemorrhage and sepsis following cholecystec…
Mrs Jeanette Brown, 66, died from multi-organ failure following post-operative haemorrhage after elective laparoscopic cholecystectomy. Arterial clips applied to the cystic artery during surgery were inadequately secured…
24y · Male·Cardiac arrest in a man with Sotos syndrome and multiple comorbidities, includin…
Joshua Fredrik Van Malssen, a 24-year-old man with Sotos syndrome, complex cardiac disease, asthma, and obesity, died from cardiac arrest after being restrained in the prone position during a lawful arrest by Public Tran…
55y · Male·gastrointestinal haemorrhage due to oesophageal varices due to hepatocellular ca…
… and cirrhosis with ultrasound screening for hepatocellular carcinoma; better detection of subtle liver dysfunction markers; adoption of newer non-invasive testing such as Fibroscan; and establishment of standardised pr…
62y · Male·multi organ failure due to atypical pneumonia
William Gripton, 62 years old with post-polio syndrome, presented to Kangaroo Island Hospital with upper respiratory tract infection that progressed to atypical pneumonia causing multi-organ failure and death. Critical c…
7y · Female·multiorgan failure due to fulminant sepsis (Streptococcus pyogenes)
7-year-old Aishwarya Aswath Chavittupara died from multiorgan failure due to fulminant sepsis (Streptococcus pyogenes) after approximately 90 minutes in Perth Children's Hospital emergency department. She presented with …
Toxicity from intravenous caesium, DMSO, and other substances administered as pa…
In May 2005, the Kathi Preston Memorial Health Centre (KPMHC) operated an unproven cancer therapy clinic from Dr B.'s home in Perth, Western Australia, administering intravenous treatment containing caesium, DMSO, and La…
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