32 results
69y · Male·peritonitis due to perforated bowel
Mr Deleman was a 69-year-old man with untreated schizophrenia, advanced liver cirrhosis, and hepatitis C, presenting to hospital on 1 April 2024 with abdominal swelling. He was admitted to The Canberra Hospital and place…
69y · Male·thoracic aortic aneurysm with dissection
Peter Hanisch, a 69-year-old man, died from thoracic aortic aneurysm with dissection on 22 August 2021. He presented to Calvary Hospital on 19 August 2021 with sudden chest discomfort and neurological symptoms. A CT angi…
43y · Female·Severe diffuse hypoxic brain injury caused by administration of supratherapeutic…
A 43-year-old woman died from severe diffuse hypoxic brain injury caused by excessive sodium bicarbonate administration during treatment of amitriptyline overdose. The treating ED consultant prescribed sodium bicarbonate…
5y · Female·myocarditis
A five-year-old girl died from fulminant myocarditis caused by influenza A on 5 July 2022 at Canberra Hospital. The diagnosis was delayed over 7 hours from initial presentation. Critical failures included: ED triage Cate…
73y · Female·Multi organ failure due to adhesions related bowel perforation (surgically treat…
Sharyn Kaine, a 73-year-old woman, died from multi-organ failure due to adhesions-related bowel perforation and paracetamol-induced liver failure. She was prescribed intravenous paracetamol 1g four times daily post-opera…
0y · Male·Hypoxic-ischemic encephalopathy and massive subgaleal haemorrhage, both associat…
Baby X, born at Canberra Hospital after a prolonged labour, died at age 2 days from injuries sustained during birth. Two interlinked pathologies contributed to death: hypoxic-ischemic encephalopathy (HIE) from prolonged …
23y · Male·Drowning
Najeebullah Rafee, a 23-year-old ANU international relations student and Afghan refugee, drowned on 25 October 2020 at Cotter Bend, a promoted ACT river recreation area. A non-swimmer, he attempted to use a small flotati…
43y · Female·Complications of morbid obesity, including progressive respiratory and cardiac f…
Nicole Abbott, 43, died from complications of morbid obesity (BMI 54.4) including progressive respiratory and cardiac failure, exacerbated by smoking and obstructive sleep apnoea. She was subject to a Psychiatric Treatme…
17y · Male·Circulatory failure caused by traumatic brain injury from being struck by a log
Christiaan Adriaan Roodt, a 17-year-old Year 10 student, died from traumatic brain injury when struck by a 6-metre log during a 'Capture The Flag' game at Mount Ainslie, near his school. Key clinical lessons: (1) The ina…
79y · Female·medication related cardiac arrest (verapamil and propranolol) in a patient with …
Mrs Patricia Croxon, a 79-year-old admitted with community-acquired pneumonia, died from medication-related cardiac arrest caused by verapamil and propranolol. The verapamil was charted in immediate release form when she…
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
Maarouf El-Cheikh, a 57-year-old man with splenectomy history, presented to Calvary Hospital ED with sepsis on 21 March 2016 and died 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadeq…
25y · Male·Cardiorespiratory arrest due to aspiration pneumonia and hypoxic-ischaemic encep…
Dean Brice, aged 25, died from accidental multiple drug toxicity (methamphetamine and GHB) causing cardiorespiratory arrest, aspiration pneumonia and hypoxic-ischaemic encephalopathy. He was subject to a Psychiatric Trea…
Bearham: hypoxic brain injury from hanging; Fisher: asphyxiation from hanging by…
Four inpatient suicides occurred at The Canberra Hospital mental health units between January 2015 and November 2016: three by hanging and one by jumping. The coroner found systemic failures including inadequate ligature…
54y · Female·Multiple organ failure, due to pneumonia in a patient with Guillain-Barré syndro…
Julie Ann Hermans, a 54-year-old Aboriginal woman with Guillain-Barré syndrome, quadriplegia, diabetes, and recurrent infections, died from multiple organ failure due to hospital-acquired pneumonia during an ICU admissio…
36y · Male·Septicaemia and cerebral artery air embolism, due to complications related to cl…
Jamie Lawrence Mitchell, 36, died from septicaemia and cerebral artery air embolism complicating radiofrequency ablation for atrial fibrillation. He developed an atrioesophageal fistula after cardiac ablation at Royal Ad…
75y · Female·cardiac arrest in the context of aortic stenosis (moderate to severe), coronary …
A 75-year-old woman with significant cardiac history (aortic stenosis, coronary artery disease, left ventricular hypertrophy) underwent elective ankle ulcer debridement surgery. She developed refractory hypotension post-…
72y · Male·Haemopericardium due to anti-coagulation treatment for pulmonary thromboemboliti…
Jeffrey Brown, a 72-year-old with recent cardiac surgery (CABG), died from haemopericardium due to anticoagulation treatment for pulmonary thromboembolism. Post-mortem examination revealed fibrinous pericarditis (a known…
43y · Male·hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic …
Jay Alan Paterson, a 43-year-old man with chronic pain and opioid dependence, died from hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic upper airway injury. He obtained 296 oxycodone table…
43y · Female·cardiac arrhythmia (unascertained), probably fatal cardiac dysrhythmia
A 43-year-old woman collapsed at home and was found in cardiac arrest after 20-25 minutes. Ambulance arrived and recognised ventricular fibrillation but failed to defibrillate for approximately 20 minutes, despite protoc…
50y · Male·Multi-organ failure caused by low flow ischaemia of coeliac artery and superior …
Adrian Van Die, a 50-year-old with severe ischaemic cardiomyopathy, underwent coronary artery bypass grafting with intra-aortic balloon pump (IABP) support. The first IABP ruptured intraoperatively and was replaced. The …
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