74 results
78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …
A 78-year-old woman died from hypoxic ischaemic encephalopathy following an acute post-surgical arterial bleed that obstructed her airway after hemithyroidectomy. The bleeding complication occurred when she coughed after…
62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (su…
A 62-year-old man died from intraoperative haemorrhage during surgery for a renal tumour initially diagnosed as benign anastomosing haemangioma on biopsy but found at autopsy to be metastatic clear cell renal cell carcin…
76y · Female·Head injury comprised of subdural haematoma, subarachnoid haemorrhage with brain…
A 76-year-old woman died from complications of a severe head injury sustained in a motor vehicle collision. She was initially managed conservatively at a regional hospital, but her condition deteriorated markedly at 9pm …
78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…
78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). T…
23y · Male·Hypoxic ischaemic encephalopathy due to near-drowning
A 23-year-old Indian citizen drowned at an unpatrolled, hazardous beach on Stradbroke Island after becoming caught in a rip current. He was unable to swim. Despite prompt CPR by lifeguards and paramedics with return of s…
64y · Male·Peritonitis, due to or as a consequence of a ruptured gallbladder, due to or as …
Dennis Childs, a 64-year-old Indigenous man serving a life sentence, died from peritonitis secondary to a ruptured gallbladder. On 8 December 2018, he presented with abdominal pain at the correctional centre but refused …
0y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…
A 10-month-old boy died following elective cleft palate repair surgery complicated by post-operative respiratory distress and subsequent cardiorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pu…
24y · Male·Multiple organ failure due to or as a consequence of severe thermal burns
Omid Masoumali, a 24-year-old Iranian refugee detained on Nauru under Australian offshore processing arrangements, suffered severe thermal burns (>50% TBSA) on 27 April 2016 after self-immolating at the Nibok settlement.…
44y · Male·Cardiac arrhythmia during physical restraint
Taare Rangi, a 44-year-old man with bipolar affective disorder, died from cardiac arrhythmia during physical restraint in a mental health unit. Critical failures occurred at multiple levels: (1) the decision to acutely s…
87y · Female·Hypoxic-ischaemic encephalopathy secondary to cardiac arrest, with valvular hear…
An 87-year-old woman died following a CT-guided epidural injection at a private radiology clinic. Although she had undergone the procedure for spinal pain, the radiologist performed an epidural injection at the T12 level…
76y · Female·multisystem organ failure due to or as a consequence of ischaemic small intestin…
A 76-year-old woman presented to hospital with abdominal pain and was found on CT scan to have ischaemic colitis with signs of profound shock. The Consultant Surgeon decided on conservative management with fluid resuscit…
12y · Male·Cardiac haemorrhage due to or as a consequence of congenital aortic stenosis (su…
Joshua Statis, a 12-year-old with complex congenital aortic stenosis, died 18 days after a redo Konno procedure and aortic valve replacement when a CardioCel patch to the right ventricular outflow tract (RVOT) ruptured, …
0y · Female·Intracranial and intrapulmonary haemorrhage due to traumatic head injury from fa…
Baby M died shortly after birth on 11 February 2016 at Gladstone Base Hospital from intracranial and intrapulmonary haemorrhage due to traumatic head injury from a fall, complicated by Group B Streptococcal sepsis. A nur…
24y · Male·Hypoxic-ischaemic encephalopathy, due to or as a consequence of cardiac arrest, …
Hamid Khazaei, an Iranian asylum seeker aged 24, died on 5 September 2014 after contracting a leg infection (Chromobacterium violaceum) on Manus Island while in immigration detention. His death was preventable and result…
Unknown·acute fentanyl toxicity; acute oxycodone toxicity; multiple drug toxicity; opioi…
Four adults died from opioid overdoses (fentanyl and oxycodone) in Queensland between 2012–2014. All obtained prescriptions from multiple doctors ('doctor shopping') without effective detection. Systemic failures include…
43y · Male·Multi-organ failure with coagulopathy secondary to acute exacerbation of chronic…
A 43-year-old man with a colloid cyst of the third ventricle presenting with progressive headache was admitted for planned endoscopic surgery. Surgery was delayed from Friday to Monday due to unavailability of specialist…
76y · Male·Coronary atherosclerosis in the context of obesity, obstructive sleep apnoea, an…
A 76-year-old man with significant comorbidities including severe obstructive sleep apnoea, obesity, aortic stenosis, and ischaemic heart disease died from acute coronary atherosclerosis 36 hours after elective sacroilia…
78y · Female·multi-organ failure due to haemorrhage into the abdomen, pelvis and retroperiton…
78-year-old Jehovah's Witness died from multi-organ failure secondary to intra-abdominal and retroperitoneal haemorrhage following extensive anterior and posterior lumbar spinal fusion surgery. The patient had multiple c…
59y · Female·Global cerebral oedema due to hypoxic cerebral ischaemia following cardiac arres…
59-year-old woman admitted with newly diagnosed grade 4 glioblastoma underwent surgery 16 days later after delays during consultant's planned leave. Post-operative complications included ischaemic stroke confirmed on ima…
87y · Male·Endobronchial and pulmonary haemorrhage secondary to pneumonia complicating chro…
An 87-year-old man with atrial fibrillation on warfarin underwent elective bronchoscopy for suspected lung lesion. The admitting respiratory team incorrectly documented a mechanical aortic valve replacement when he actua…
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