60y · Female·Tachyarrhythmia and hyperkalaemia leading to sudden cardiac death in the setting…
…ld woman with intellectual disability living in supported accommodation, died from tachyarrhythmia and hyperkalaemia leading to sudden cardiac death in atrial fibrillation. She had been diagnosed with atrial fibrillatio…
87y · Female·digoxin toxicity with hyperkalaemia
…are with 26 vials of DigiFab antidote, she suffered cardiac arrest and died from digoxin toxicity with hyperkalaemia. The coroner found that hospital staff took all possible steps to prevent her death. This case illustr…
42y · Male·Cardiac arrhythmia secondary to electrolyte imbalance (hyperkalaemia) and verapa…
…ttempting to fulfill what he misunderstood. (2) ED response – on second presentation with bradycardia, hyperkalaemia, and ECG changes suggesting life-threatening electrolyte disturbance, staff failed to recognise severi…
82y · Female·Hyperkalaemia due to acute renal failure on a background of end stage pulmonary …
…-old woman with terminal pulmonary fibrosis and chronic respiratory failure presented with chest pain, hyperkalaemia and metabolic acidosis. She became combative and was given haloperidol and morphine for agitation. The…
39y · Female·Sepsis and renal failure secondary to a perinephric abscess
…d supportive care, her condition deteriorated rapidly. A second planned operation was cancelled due to hyperkalaemia and clinical decline. Palliative care was implemented following discussions about poor prognosis, and …
72y · Male·metastatic prostate carcinoma
Timothy Moffatt, a 72-year-old man in prison custody, died from metastatic prostate cancer. He had declined cancer treatment from 2014-2018 but agreed to chemotherapy after metastatic disease was identified. He also had …
71y · Female·Complications of cerebral palsy
…ctly cause her death but impacted service quality. Key issues included: inconsistent management of her hyperkalaemia dietary requirements, inadequate record-keeping of fluid and food intake, and failure to maintain curr…
64y · Male·Septic shock secondary to urosepsis (Pseudomonas and Stenotropomonas maltophilia…
…tment with suspected sepsis (vomiting, diarrhoea, hypotension, acute kidney injury, elevated troponin, hyperkalaemia, metabolic acidosis). The locum doctor and nurses failed to recognize sepsis or clinical deterioration…
39y · Male·Multidrug toxicity (GHB, methylamphetamine, ketamine) in a setting of restraint …
Anthony Parisi, 39, died from multidrug toxicity (GHB, methamphetamine, ketamine) in a setting of police restraint and moderate coronary artery atherosclerosis. He consumed large quantities of GHB and methamphetamine on …
58y · Male·Acute renal failure in the setting of pneumonia and acute bronchitis
…h abdominal distension and respiratory compromise, developing severe heart failure, renal failure with hyperkalaemia, and respiratory failure during admission. No primary cause was identified despite investigations. The…
33y · Male·Fatal cardiac arrhythmia, secondary to acute kidney injury
…38 hours post-operatively from a fatal cardiac arrhythmia secondary to acute kidney injury with severe hyperkalaemia. Pre-operative assessment identified significant risks (obesity, hypertension, probable sleep apnoea) …
77y · Male·Complications of metastatic squamous cell carcinoma, likely urothelial origin
…r 2020. He had been diagnosed with bladder cancer in July 2020 after presenting with hyponatraemia and hyperkalaemia. Multiple specialist reviews (urology, oncology) determined he was unsuitable for systemic therapy due…
Unknown·Panella: pulmonary thromboembolism due to left calf deep vein thrombosis; Skeffi…
…utes before admission; Graham Jessett (64) died from ischaemic heart disease complicated by undetected hyperkalaemia. Panella's death was not preventable given her rapid deterioration and atypical presentation, but occu…
17y · Male·mixed drug toxicity (25C-NBOMe and 4-fluoroamphetamine)
…ed drug markets. He experienced severe symptoms including seizures, agitation, metabolic acidosis, and hyperkalaemia requiring ICU admission with maximal vasopressor support and full medical resuscitation. Despite aggre…
71y · Male·acute pyelonephritis with contributing ischaemic heart disease
A 71-year-old male prisoner died from acute pyelonephritis with contributing ischaemic heart disease at Flinders Medical Centre. He had advanced metastatic gastric cancer diagnosed in February 2011 after presenting with …
73y · Male·Acute on chronic renal failure and multi-factorial encephalopathy in a man with …
A 73-year-old man with significant comorbidities (cirrhosis, dilated cardiomyopathy, chronic kidney disease) died in prison from acute-on-chronic renal failure, hepatic encephalopathy, and multiorgan failure. He was init…
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 dangerously…
65y · Male·Multi-organ failure in a man with an ischaemic right leg treated with opioids
A 65-year-old man with multiple chronic conditions (COPD, cardiac failure, diabetes, obesity) was admitted with pneumonia and severe ischaemic right leg pain. Opioid analgesia for the leg pain precipitated delirium, requ…
76y · Male·Small bowel obstruction and acute renal failure, due to or as a consequence of m…
Adrian Adams, aged 76, died in Princess Alexandra Hospital from small bowel obstruction and acute renal failure secondary to metastatic colorectal cancer. He was serving an eight-year sentence for sexual offences at the …
27y · Male·Complications of snake bite
Shane Kyle Tatti, a 27-year-old gardener, died from complications of tiger snake envenomation. After a vigorous bite on 6 November 2014, he received one vial of tiger snake antivenom at Orbost Hospital 62 minutes post-bi…
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