33y · Male·toxic effects of oxycodone
…codone toxicity after his general practitioner prescribed escalating doses of the opioid for intermittent migraines over 14 months (5-30mg daily), despite a prior rejection of a pethidine application for the same indicat…
41y · Female·frontal lobe ischaemic infarcts (strokes) caused by cerebral artery vasospasm co…
…sode. Critical failures occurred at the Royal Hobart Hospital ED on 18 July when staff rapidly accepted a migraine diagnosis without sufficiently considering subarachnoid haemorrhage or reviewing available ambulance note…
54y · Female·Multi-organ failure following a decreased level of consciousness caused by compl…
… obstructive and central sleep apnoea complicated by sedating substances. On 2 June 2008, while suffering migraine, she self-medicated with cannabis and both her own and her husband's sedating medications (diazepam, benz…
57y · Female·Multi-organ failure due to drug-induced liver injury caused by sodium valproate …
Mrs Doherty, a 57-year-old woman with CADASIL syndrome, was prescribed sodium valproate for migraine prophylaxis in November 2019. She developed acute hepatitis approximately 5 months later, presenting with…
46y · Female·brain swelling and dural venous thrombosis in association with low grade glioma …
…headache characterized by pulsatile pain, photophobia, vomiting, and visual disturbances. Dr G. diagnosed migraine based on her history and symptoms, but failed to conduct comprehensive neurological examination or assess…
25y · Male·cerebral craniopharyngioma
…ict Hospital on 11 August 2002 with a persistent headache. He was seen by Dr H. (registrar) who diagnosed migraine and commenced symptomatic treatment. He was admitted overnight under Dr T. (RMO) with 2-hourly neurologic…
29y · Female·respiratory depression caused by morphine intoxication on a background of upper …
…tical lessons include: correct morphine dosing based on age not weight; morphine contraindicated in acute migraine; mandatory documented observation protocols when opioids administered, especially in morphine-naïve patie…
65y · Male·complications of intracranial haemorrhage (hypertensive haemorrhage), with termi…
…s managed palliatively. Key clinical lessons include: (1) an outstanding neurology referral for recurrent migraines with aura was never completed—an MRI may have identified an aneurysm amenable to monitoring or surgical …
25y · Female·mixed drug toxicity
Rachel Smith, a 25-year-old woman with chronic migraines and depression, died from mixed drug toxicity after consuming multiple prescription medications includin…
64y · Male·plastic bag asphyxia
A 64-year-old man with long-standing depression, personality disorder, and chronic pain died by plastic bag asphyxiation in a psychiatric hospital open ward. He had been admitted involuntarily after expressing suicidal i…
31y · Female·right cerebellar cerebrovascular accident (cerebellar infarction with obstructiv…
…d speech difficulties. Initial CT brain showed equivocal left temporal hypodensity. Dr B. diagnosed acute migraine/benign positional vertigo and ordered lumbar puncture to exclude encephalitis, delaying neurological cons…
26y · Female·morphine toxicity complicated terminally by bronchopneumonia
A 26-year-old woman with chronic migraines and depression died from morphine toxicity complicated by aspiration pneumonia. She had a documented his…
13y · Male·Self-inflicted (manner recorded as intentionally self-inflicted; specific method…
A 13-year-old boy with depression, migraine, school refusal and family instability died by intentional self-inflicted means. His general practitioner…
Unknown·Michael William Dunk: gunshot wounds to upper abdomen and head. Elishka Dawn Joh…
This finding concerns two deaths arising from a domestic tragedy involving relationship breakdown. Michael William Dunk (46) was shot by his de facto partner Elishka Dawn Johnson (41) on 8-10 April 2015 at their Tasmania…
31y · Female·raised intracranial pressure due to ventriculoperitoneal shunt dysfunction (disc…
… the neurology team misinterpreted findings alongside a reassuring shunt flow study and discharged her as migraine. The imaging was never reviewed by an experienced neurosurgeon. Her mother repeatedly raised concerns abo…
60y · Female·Multiple injuries sustained in a motor vehicle incident (driver)
Christina Maree Chamberlain, aged 60, died when her vehicle drifted across lanes and collided with a tree on Great Alpine Road. She was taking multiple medications including oxycodone, amitriptyline, sertraline, diazepam…
41y · Male·subarachnoid haemorrhage due to rupture of a berry aneurysm of the right interna…
…y rupture of an undiagnosed berry aneurysm while incarcerated. He had a complex medical history including migraines, head injuries, hypertension, and substance use. In June 2021, he presented with right facial pain initi…
46y · Female·Hypoxic brain injury due to combined drug toxicity
Donna Mousley, aged 46 years with long-standing panadeine forte and diazepam dependence, presented to an addiction medicine specialist seeking management. Dr C. prescribed methadone 40mg on 9 November 2010 after consulta…
39y · Female·Mixed drug toxicity (methadone, oxycodone, hydromorphone, mirtazapine, diazepam,…
A 39-year-old woman with chronic pain from a previous work injury died from mixed drug toxicity involving methadone, oxycodone, hydromorphone, diazepam, mirtazapine, and promethazine. Her pain specialist prescribed metha…
34y · Female·Multi drug toxicity
Jodie Overstead, a 34-year-old with epilepsy, anxiety, and chronic pain, died from multi-drug toxicity involving tramadol, codeine, amitriptyline, benzodiazepines and other drugs. She engaged in 'doctor shopping', obtain…
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