3y · Female·massive air embolism
…re cuff that forced both fluid and air through the IV line into the patient's circulation. At 250 mL/hour infusion rate, fluid exhausted after ~24 minutes, sending ~70-100 mL of air directly into her bloodstream. Clinica…
54y · Male·Toxic leukoencephalopathy (of uncertain aetiology)
…e injuries and opioid dependence (330mg morphine equivalents daily). Dr T. initiated a seven-day ketamine infusion protocol with supportive medications. David became unexpectedly drowsy and developed fluctuating consciou…
74y · Female·empyema/sepsis complicating oesophageal perforation following a complicated elec…
…spects, though oesophageal perforation carries inherently high mortality. An additional error was calcium infusion via peripheral vein causing arm tissue damage; central venous access should have been used.
48y · Female·Aspiration of stomach contents and pneumonia, following cardiac arrest
Margaret Webber, aged 48, with cerebral palsy and diabetes, died from aspiration of stomach contents and pneumonia. She presented to hospital with diabetic ketoacidosis (DKA) and coffee-ground vomit, which raised concern…
31y · Female·drowning, deliberately self-inflicted with intention of ending life
…nd lamotrigine overdose, during which she required mechanical restraints and life-saving N-acetylcysteine infusion. The coroner found her treatment at RHH was appropriate and likely life-saving, with excellent nursing ca…
51y · Male·respiratory failure and cardiac failure on a background of chronic obstructive l…
Colin Peter Smith, aged 51, died of respiratory and cardiac failure from acute pulmonary oedema and pneumonia on a background of chronic obstructive lung disease and ischaemic heart disease. He presented to the Royal Ade…
39y · Male·rhabdomyolysis complicating cocaine toxicity against a background of atheroscler…
A 39-year-old man with undiagnosed atherosclerotic coronary artery disease died from rhabdomyolysis complicating cocaine toxicity. He exhibited cocaine-induced excited delirium with erratic dangerous driving and bizarre …
80y · Female·Anaphylaxis complicating chemotherapy for the treatment of metastatic fallopian …
…an with metastatic fallopian tube cancer, died from anaphylaxis during her third carboplatin chemotherapy infusion. She had experienced a documented Grade 2 hypersensitivity reaction to carboplatin during her second trea…
21y · Female·Multiple organ failure due to undefined sepsis (toxic shock syndrome)
Amanda Dana Tauai, 21 years old, died from septic shock with multi-organ failure in March 2012 after presenting with symptoms initially consistent with viral gastroenteritis and dehydration. Initial management at remote …
56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy
A 56-year-old woman presented to Knox Private Hospital with severe headache and eye symptoms on 16 June 2007. An ED physician diagnosed ischaemic stroke based on a subtle CT finding in the absence of focal neurological s…
0y · Female·Persistent pulmonary hypertension in the newborn (PPHN)
Summer Jamsek was born at 4pm on 4 April 2010 with persistent pulmonary hypertension of the newborn (PPHN) and died 5 April 2010 at Royal Children's Hospital. The coroner found Baby Summer died from PPHN but was not sati…
17y · Male·fatal asphyxia resulting from severe upper airway obstruction secondary to acute…
Kieran Watmore, a fit 17-year-old male, died from fatal asphyxia at Albany Regional Hospital on 28 August 2008 while being treated for acute tonsillitis. He presented to ED on 27 August with severe throat pain and was pr…
28y · Male·Hanging
Daylon Roeton, 28, died by hanging in a mental health seclusion room using a ligature made from blanket binding. He was admitted involuntarily after expressing suicidal ideation and paracetamol overdose. The coroner foun…
64y · Male·Septic shock secondary to urosepsis (Pseudomonas and Stenotropomonas maltophilia…
RD, a 64-year-old man with diabetes, amputation, and COPD, presented to a private hospital emergency department with suspected sepsis (vomiting, diarrhoea, hypotension, acute kidney injury, elevated troponin, hyperkalaem…
17y · Male·Hypoxic Ischaemic Encephalopathy Complicating Anaphylaxis
James Tsindos, a 17-year-old with known nut allergy and mild asthma, experienced anaphylaxis after inadvertently ingesting cashews in a vegan restaurant meal on 27 May 2021. Ambulance paramedics administered two doses of…
3y · Male·Influenza A infection (Type H3N2)
Aidan Mara, a 3-year-old boy with influenza A pneumonia and hyponatraemia, collapsed and died from cardiovascular failure on hospital day 3. Critical clinical lessons include: (1) distinguishing SIADH from dehydration ea…
0y · Female·Intra-uterine hypoxia
Baby Paula O'Shea was born at Sandringham Hospital at term following spontaneous labour. Labour was augmented with IV Syntocinon after ARM. Cardiotocography (CTG) monitoring was difficult to interpret due to poor detecti…
66y · Female·Cardiac failure due to atherosclerotic and hypertensive heart disease
A 66-year-old woman died from cardiac failure due to atherosclerotic and hypertensive heart disease. She presented to a rural GP with ankle oedema, cough, and palpitations during interstate travel. The GP diagnosed mild …
Toxicity from intravenous caesium, DMSO, and other substances administered as pa…
…operated an unproven cancer therapy clinic from Dr B.'s home in Perth, Western Australia, administering intravenous treatment containing caesium, DMSO, and Laetrile under remote supervision of Dr S. from Thailand. Seven…
85y · Male·Intracranial haemorrhage in the setting of a fall in a man with multiple comorbi…
…ated to treating clinicians until 11:23pm—a 40-minute delay. By then, approximately half the thrombolytic infusion had been administered. The thrombolysis caused massive intracranial haemorrhage and death. While preventa…
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