32y · Male·Aspiration pneumonia and reflux oesophagitis
Timothy Luke Rubenach, aged 32, died of aspiration pneumonia following severe reflux oesophagitis. He had profound intellectual disability and drug-resistant epilepsy from meningococcal infec…
39y · Male·Ischaemic heart disease with complete occlusion of the left anterior descending …
…d to GP Dr V. with chest pain on exertion (cycling, chopping wood) and arm heaviness. The doctor diagnosed reflux oesophagitis, ordered ECG and troponin testing (both normal at 3.5 hours post-symptom onset), and prescrib…
67y · Male·acute gastrointestinal haemorrhage complicating peptic ulcer of the duodenum wit…
…(2) Proton pump inhibitor (Esomeprazole) charting failed from 6 August onwards despite the patient's known reflux oesophagitis and pre-admission use of Rabeprazole; multiple practitioners failed to recognize this omissio…
59y · Female·Pneumonia
Tamara Kudeviita, a 59-year-old woman with Down's syndrome and advanced Alzheimer's disease, died of pneumonia in a palliative care unit. She had been declining throughout 2022, with loss of swallowing ability, mobility,…
72y · Female·Bronchopneumonia
Diane Young, a 72-year-old psychiatric resident with multiple comorbidities including asthma, aortic stenosis, and intellectual disability, died of bronchopneumonia with contributing ischaemic heart disease. She was seen…
45y · Male·choking on food
Richard Mann, a 45-year-old man with intellectual disability and psychiatric illness residing in an institutional setting (Strathmont Centre infirmary), died from choking on food. Critical failures in observation and mon…
44y · Male·aspiration pneumonia
Christopher Hollens, a 44-year-old man with chronic schizophrenia, traumatic brain injury, spastic paraparesis, and epilepsy, died of aspiration pneumonia after a 15-day admission to Royal Adelaide Hospital. He was trans…
80y · Male·aspiration pneumonia
Ernest Charles Willetts, 80, died from aspiration pneumonia following an appendectomy. On hospital day 3, he developed coffee-ground vomitus indicating gastrointestinal bleeding. A gastroscopy was performed that afternoo…
89y · Male·Complications of choking on a food bolus in a man with multiple medical comorbid…
Maurice Benedict Costello, 89, died from aspiration of a food bolus while eating on a geriatric ward three days after a fall. He had documented oropharyngeal dysphagia requiring supervision during oral intake. Speech pat…
60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…
James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…
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