12 results
84y · Male·Respiratory failure complicating hospital acquired pneumonia following surgical …
An 84-year-old man died from respiratory failure due to hospital-acquired pneumonia following surgery for recurrent mandibular squamous cell carcinoma. Key clinical lessons: (1) Advanced Care Plans (ACPs) must be activel…
42y · Male·hanging
A 42-year-old prisoner with generalised anxiety disorder and chronic tinnitus causing significant distress died by suicide while incarcerated. In the months preceding his death, he presented repeatedly to health staff re…
50y · Male·Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (t…
A 50-year-old man died from tracheostomy site haemorrhage 36 days after laryngectomy for recurrent laryngeal cancer. He lived alone post-discharge with a MePACS personal alarm system and home nursing visits. When bleedin…
69y · Male·Hypoxic ischaemic brain injury secondary to right facial artery pseudoaneurysm r…
69-year-old male with tonsillar squamous cell carcinoma presenting with throat pain and trismus 12 days after completing chemoradiotherapy. On presentation to emergency department with bleeding, airway risk was under-rec…
52y · Female·Neutropenic sepsis leading to multi-organ failure due to capecitabine toxicity
Mrs L, a 52-year-old woman with T2N0M0 rectal cancer, died from neutropenic sepsis and multi-organ failure secondary to severe capecitabine toxicity on 31 October 2018. She commenced neoadjuvant chemotherapy with capecit…
76y · Female·Ludwig's angina
A 76-year-old woman with Ludwig's angina presented to urgent care with facial swelling and fever. She was appropriately diagnosed and arrangements made for transfer to a tertiary centre. However, staff failed to recognis…
25y · Female·Airway obstruction complicating laryngeal dilation for the treatment of subglott…
Ms Sobb, a 25-year-old woman with spondylo-epi-metaphyseal dysplasia causing severe airway abnormalities and subglottic stenosis, died from airway obstruction following laryngeal dilation. She was admitted to ICU with as…
4y · Male·Complications of T-cell lymphoma
Nghi Pham was a 4-year-old admitted to Sunshine Hospital with facial swelling, stridor, and upper respiratory symptoms. He was examined by emergency and ENT teams, diagnosed with adenoiditis and sinusitis, and discharged…
2y · Male·Tramadol toxicity in the setting of adenotonsillectomy in a child with Pierre Ro…
Dane Hortle, a 2-year-old with Pierre Robin Sequence and obstructive sleep apnoea, died from tramadol toxicity following adenotonsillectomy. He was discharged with a prescription for tramadol 25mg, which was dispensed as…
15y · Male·global hypoxic cerebral injury following medical intervention for high velocity …
Daniel Cowan, aged 15, sustained a penetrating head injury from a homemade air gun while with friends. Despite appropriate emergency response and comprehensive multidisciplinary medical management at Royal Children's Hos…
4y · Male·hypoxic brain injury complicating out of hospital cardiac arrest (unknown cause)
Xavier Hart, a 4-year-old boy with obstructive sleep apnoea due to adenotonsillar hypertrophy, was found unresponsive and apnoeic at home on 21 December 2011. Despite immediate CPR and intensive resuscitation, he suffere…
2y · Female·pneumonia in a toddler with enlarged tonsils and presence of codeine in blood
Elanur Koc, a 2-year-old with a history of recurrent throat infections and enlarged tonsils, died from pneumonia. Significant codeine was detected in her blood, urine, liver, and stomach contents, with codeine also prese…
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