83y · Female·Gunshot wound to the head
… from a gunshot wound to the head on 3 November 2016. She had extensive cardiac history including multiple valve replacements, pacemaker insertion, and congestive heart failure diagnosed in 2016. Two hospital admissions…
49y · Male·Acute myocardial infarction complicating prosthetic valve thrombosis in a man wi…
Joshua Paul Coates, aged 49, died from acute myocardial infarction complicating prosthetic valve thrombosis following mechanical aortic valve replacement. Post-mortem examination revealed a large…
87y · Male·Endobronchial and pulmonary haemorrhage secondary to pneumonia complicating chro…
…scopy for suspected lung lesion. The admitting respiratory team incorrectly documented a mechanical aortic valve replacement when he actually had a tissue valve; warfarin was for atrial fibrillation, not the valve. This…
43y · Male·Complications of valvular heart disease
…es Batten, a 43-year-old with intellectual disability and schizophrenia, died from complications of aortic valve stenosis. A transoesophageal echocardiogram in June 2022 demonstrated severe aortic stenosis requiring val…
77y · Female·haemorrhagic diathesis due to warfarin toxicity
…, died from haemorrhagic diathesis due to warfarin toxicity after 84 days in a rural hospital. She had a prosthetic aortic valve requiring anticoagulation. INR monitoring was inadequate: no tests for 36 days (July 28–Sep…
37y · Male·Coronary artery thrombosis resulting from coronary atherosclerosis with contribu…
Marshall Yantarrnga, a 37-year-old Aboriginal man with significant cardiac history (prior mitral valve replacement in 1996), presented with chest and right-sided pain, fever, and was assessed by ambulance offi…
68y · Female·acute gastrointestinal haemorrhage secondary to bilateral dental extraction
A 68-year-old woman on long-term warfarin therapy for a prosthetic aortic valve died from acute gastrointestinal haemorrhage following dental extraction. The dentist faile…
68y · Male·Dilated cardiomyopathy with previous aortic valve replacement and aortic graft
A 68-year-old man with aortic valve replacement died from undiagnosed dilated cardiomyopathy, with retroperitoneal haemorrhage as a contributi…
63y · Male·pneumonia complicating anoxic brain injury, due to post-operative haemorrhage as…
…-operative haemorrhage from the inferior epigastric artery during ileostomy closure surgery. The critical failure was a 2.5-hour delay (0530-1100 hours) in obtaining intravenous access and blood results that would have …
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