89y · Male·fractured cervical spine (C5 inferior articular process fracture) due to unwitne…
…spine fracture. Initial CT imaging missed the C5 inferior articular process fracture, reporting only a paraspinal haematoma. Conservative management with mobilisation by an occupational therapist caused ligament disrupti…
51y · Male·metastatic small round cell malignancy (Ewing's Sarcoma)
… in custody. He presented with urinary retention and lower limb weakness in January 2018, underwent urgent spinal decompression surgery, and was subsequently diagnosed with advanced metastatic cancer. Palliative care was…
12y · Female·Raised intracranial pressure due to acute-on-chronic hydrocephalus in the contex…
Samantha Rose Spence, 12 years old, died two days after spinal fusion surgery for severe scoliosis. She had a pre-existing, asymptomatic Chiari type 1 malformation detec…
80y · Male·haemorrhagic stroke caused by Staphylococcus aureus sepsis due to L4/5 discectom…
An 80-year-old man underwent elective microdiscectomy for spinal pain in April 2023. In late June, he developed a wound infection with Staphylococcus aureus causing discit…
45y · Male·Bronchopneumonia
…rom January 2008, including loss of mobility, incontinence, and development of infected pressure ulcers. An MRI in May 2008 confirmed severe cervical myelopathy unsuitable for surgery. Management focused on conservative…
84y · Male·Pneumonia complicating fractured cervical spine in the setting of fall
…developed later and was complicated by loss of intercostal and accessory breathing muscles due to the C5-6 spinal injury with cord compression. The coroner found no medical intervention at an earlier stage would have cha…
33y · Male·Marburg variant of multiple sclerosis
… When acute neurological symptoms emerged on 3 December, he received comprehensive investigations including MRI, lumbar puncture, and broad-spectrum antibiotics. A neurologist appropriately recommended plasma exchange a…
76y · Male·Bronchopneumonia in a man with ischaemic heart disease and treated spinal crush …
John Hayle, a 76-year-old with Alzheimer's dementia, ischaemic heart disease, and spinal fractures sustained a T11/12 flexion-distraction fracture on 9 June 2017. Over three weeks, he developed p…
74y · Male·Pulmonary thromboembolism secondary to deep vein thrombosis in the setting of re…
…74-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis following a cervical spinal fracture. He presented to rural ED with mental health concerns, was restrained by security guards after br…
72y · Male·Upper cervical spine injury sustained in a fall from a ladder
…der during home garden maintenance, sustaining a severe upper cervical spine injury (C2 fracture with high spinal cord haemorrhage) that was deemed non-survivable. He died 2 days later in ICU after palliative care. The c…
29y · Male·Bronchopneumonia complicating neck injuries sustained in a fall, with Coffin-Low…
A 29-year-old man with Coffin-Lowry Syndrome suffered a severe cervical spinal cord injury from a fall at a respite facility. Disability workers found him on the floor but initially int…
43y · Male·Complications of neck injury; specifically extensive brainstem infarction second…
…Strickland, an experienced Harley Davidson rider, died from brainstem infarction following severe cervical spinal injury sustained in a motorcycle crash on Julimar Road, Western Australia. He failed to negotiate a tighte…
31y · Male·metastatic alveolar soft part sarcoma
…initiated pain complaints from 2010-2012 concerning left hip/back pain were unrelated to sarcoma; attempted MRI investigations were repeatedly cancelled but expert confirmed spinal pathology explained symptoms. After di…
40y · Male·metastatic malignant melanoma
…e inadequate and did not identify metastatic disease until the third presentation. Brain metastases and C6 spinal involvement were subsequently found. During terminal admission, he developed confusion and agitation from …
72y · Female·Pneumonia following cervical spine injuries sustained in an unwitnessed mechanic…
…bility problems, and probable dementia. While in hospital, there was a delayed identification of her C4-C6 spinal injury (approximately two weeks), caused by deviations from protocols and incomplete neurological observat…
43y · Male·hypoxic brain injury secondary to asphyxiation by ligature
…ain injury due to asphyxiation by ligature while an inpatient at a rehabilitation centre. He had undergone spinal surgery for back pain and cauda equina syndrome but was failing to improve. On 10 April, nursing staff lea…
58y · Male·metastatic adenocarcinomatosis with unknown primary source
A 58-year-old prisoner died of metastatic adenocarcinoma with unknown primary. In September 2006, significantly abnormal liver enzymes (GGT 2093) and hyperglycemia were detected. A December 2006 ultrasound identified an …
0y · Female·brain death complicating head and neck injury
A five-month-old girl died from catastrophic brain injuries caused by violent shaking on 20 May 2019. Medical evidence established she was shaken by an adult on at least two occasions: once around 6 May 2019 (evidenced b…
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