89y · Male·septicaemia due to infected groin wound, femoropopliteal bypass in a man with mu…
…d man with multiple comorbidities (diabetes, peripheral vascular disease, heart failure) developed a groin wound infection following femoropopliteal bypass surgery while residing in aged care. The wound deteriorated rap…
45y · Female·Complications of sepsis secondary to sacral pressure wound in a woman with genet…
…ration prevention (requiring upright positioning). Although Aruma disability support staff who dressed the wound on 4-5 July 2024 had not completed formal pressure care training, the coroner found this misstep was not c…
79y · Male·Complications of peripheral vascular disease with Type 2 Diabetes Mellitus, atri…
…function, cardiac failure, and episodes of aspiration. While early prison health records contained gaps in wound dressing documentation, Forensic Medicine advice concluded that lapses in correctional facility wound care…
12y · Male·Cardiac haemorrhage due to or as a consequence of congenital aortic stenosis (su…
… right ventricular outflow tract (RVOT) ruptured, causing catastrophic bleeding. He developed a sternotomy wound infection 9 days post-operatively, returned to theatre for debridement with VAC dressing on day 15, and ac…
76y · Female·multiple organ failure due to abdominal wall cellulitis (surgically treated)
…ltiple organ failure secondary to abdominal wall cellulitis. A critical care failure occurred when an old dressing left in an abdominal skin fold on 10 August 2023 was not managed with a care plan until 7 days later. The…
66y · Female·aspiration pneumonitis and gangrenous necrosis of both feet
…ty, lived on a couch, and refused hospital admission or nursing home placement. Community nurses attempted wound care but were repeatedly obstructed by the patient's combative behaviour, unrealistic demands, and refusal…
96y · Female·Pseudomonas aeruginosa sepsis secondary to infected leg ulcers, complicated by m…
…le resident in an aged care facility. Despite multiple medical reviews between February and June 2015, the wounds were not escalated to hospital care. A tendon was identified as exposed in late April 2015, requiring spe…
75y · Female·organ failure due to sepsis, likely from infected pressure sores, in the context…
…abetes and ischaemic heart disease, died from septic shock secondary to extensive infected sacral pressure wounds. She received home care through KinCare for approximately 9 months, during which her condition deteriorat…
85y · Female·Staphylococcus bacteremia complicating multiple injuries sustained in a motor ve…
…ion, induced coma, and three surgical fixations. Initial recovery appeared successful, but she developed a wound infection post-discharge to rehabilitation. She was readmitted with deep wound infection, underwent washou…
87y · Female·Natural causes in the context of multiple co-morbidities including a sacral ulce…
…. Key clinical lessons: (1) Systematic communication failures—family was not informed that a healed sacral wound re-emerged in March 2016 or ulcerated by August, despite this being identified by wound consultants as req…
87y · Female·Terminal exacerbation of chronic obstructive pulmonary disease; antecedent cause…
Maureen 'Kitty' McDonald, 87, died from terminal exacerbation of COPD with an antecedent sacral pressure wound infection. She was admitted to residential aged care in October 2020 with a stage-two sacral pressure inju…
55y · Female·Complications of metastatic colorectal carcinoma
… with hepatic metastases. She underwent emergency proctolectomy on 31 July, complicated by bacteraemia and wound breakdown. After initial recovery, she developed acute illness with bowel obstruction and agitation. Palli…
29y · Male·acute bronchopneumonia complicated by multi-drug toxicity
…esic) without consulting the psychiatric team. Nicholas became profoundly sedated—sleeping through painful wound dressing—but these warnings were not escalated. He was found unresponsive at 04:00 on 22 August; resuscita…
60y · Male·Sepsis due to pressure ulcers due to immobility on a background of advancing fro…
…ility, despite appropriate preventive measures including repositioning, alternating pressure mattress, and wound dressing protocols. The ulcers became infected and he deteriorated rapidly, requiring hospitalisation wher…
48y · Female·Sepsis due to pulmonary and cutaneous infections, with urinary tract infection a…
A 48-year-old tetraplegic woman died from sepsis originating from a necrotic sacral pressure wound. Multiple system failures contributed: inadequate pressure sore prevention at the disability care provider…
34y · Female·Blunt force trauma on a background of contributing ischaemic heart disease
A 34-year-old Aboriginal woman died from blunt force trauma inflicted by her domestic partner over a prolonged period. Critical failures in police coordination and communication systems delayed apprehension of the perpet…
14y · Male·Loss of blood arising from incised wound to the left arm (cubital fossa)
A 14-year-old Aboriginal petrol sniffer brought to a remote outstation (Ilpurla) without pre-arrangement died from massive haemorrhage following a self-inflicted laceration to his arm. Clinical lessons: petrol sniffers i…
60y · Male·cardiorespiratory failure due to malignant pleural effusion due to metastatic ma…
…treated as a diabetic foot ulcer. The lesion failed to heal over 16 months despite standard care including wound dressing, antibiotics, and orthopaedic review. Malignant melanoma was diagnosed only in July 2008 followin…
45y · Male·Global cerebral hypoxia following cardio-respiratory collapse due to anaphylaxis…
A 45-year-old man with poorly controlled diabetes, ischaemic heart disease, and recurrent lower limb infections died from anaphylaxis to intravenously administered flucloxacillin. He presented with sepsis secondary to a …
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