227 results
74y · Male·Acute myocardial infarction complicated by multiple organ failure
Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…
44y · Female·Pulmonary thromboembolism complicating a fractured left ankle (not operated), su…
A 44-year-old woman died from pulmonary thromboembolism 27 days after sustaining a Weber B ankle fracture from a fall. She was managed conservatively with a CAM boot then below-knee cast, with progressive immobilisation …
53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures
Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…
70y · Male·Metastatic melanoma with ischaemic heart disease as a contributing condition
Francis Michael Fahey, a 70-year-old prisoner, died from metastatic melanoma with contributing ischaemic heart disease. He presented with a rapidly enlarging axillary mass in February 2023, confirmed as metastatic melano…
11y · Male·bronchopneumonia and small bowel necrosis with perforation, in a boy with multic…
An 11-year-old Aboriginal boy died from bronchopneumonia and small bowel necrosis with perforation, following severe neurological impairment from an inflicted brain injury sustained at 8 months old. His parents delayed s…
53y · Female·Unascertained (presumed drowned)
Kathleen Smith, a 53-year-old podiatrist, disappeared on 15 July 2024 and is presumed to have drowned at Sorrento Back Beach. She was experiencing severe anxiety about upcoming foot surgery due to severe flatfoot deformi…
87y · Female·right thigh haematoma as a consequence of a periprosthetic fracture of the right…
An 87-year-old woman with multiple comorbidities (diabetes, atrial fibrillation, peripheral vascular disease) sustained a periprosthetic fracture requiring distal femur replacement. She deteriorated significantly during …
26y · Female·Pulmonary thromboembolism due to deep vein thrombosis (left leg) due to fracture…
A 26-year-old woman with a tibia fracture died from pulmonary embolism due to deep vein thrombosis. Despite multiple risk factors (obesity, oral contraceptive use, vaping, leg immobilization, prolonged immobility), no fo…
92y · Male·Consequences of accidental fall at RACF: post-operative delirium, left femoral i…
A 92-year-old man resident in an aged care facility sustained an unwitnessed fall resulting in left hip fracture, requiring surgical fixation. He developed post-operative delirium and died 8 days later. The coroner ident…
70y · Female·pneumonia and post-surgical course following repair of neck of femur fracture, i…
Susan Mitchelmore, a 70-year-old woman with multiple comorbidities including COPD, ischaemic heart disease, diabetes, and bipolar disorder, was a resident in an aged care facility under a Mental Health Act Treatment Orde…
86y · Female·Hypostatic pneumonia due to the consequences of a right pubic rami fracture and …
An 86-year-old woman with advanced dementia and frailty suffered an unwitnessed fall at her aged care facility. Initial assessment failed to identify pubic rami and hip fractures. Post-fall documentation was insufficient…
54y · Male·Complications of pelvic and spinal fractures sustained in a fall in man with Dow…
Andrew William Barr, a 54-year-old man with Down syndrome and Alzheimer's dementia, died from complications of pelvic and spinal fractures sustained in a fall. Following his mother's death in January 2021 and his Februar…
63y · Male·pulmonary emphysema
Stanley McIntyre, a 63-year-old man with severe treatment-resistant schizophrenia, died from pulmonary emphasema on 23 June 2021 while subject to a Psychiatric Treatment Order. He had advanced COAD diagnosed only one mon…
94y · Male·aspiration pneumonia due to stroke following surgery to repair fracture of neck …
A 94-year-old man with dementia died from aspiration pneumonia following a stroke after hip surgery. The stroke and hip fracture resulted from being pushed by another resident with Alzheimer's dementia at an aged care fa…
86y · Male·aspiration pneumonia following injuries sustained in a motor vehicle crash and p…
Kenneth Warn, 86, sustained a T12 burst fracture and bilateral pleural effusions from a motor vehicle crash on 1 March 2024 while a passenger in a Mercedes panel van. The driver suddenly lost control on Tea Tree Road; th…
62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…
A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…
66y · Female·Hypoxic-ischaemic encephalopathy
A 66-year-old woman with COPD, obstructive sleep apnoea, and obesity underwent routine knee surgery at Royal Darwin Hospital. Post-operative care was inadequate. Despite dropping oxygen saturations to 88% when sedated an…
90y · Female·Surgical repair of fractured neck of femur sustained in a fall complicated by CO…
Maria Grazia Nardiello, aged 90, died following surgical repair of a fractured neck of femur sustained in a fall at an aged care facility, complicated by COVID-19 infection. She was pushed by another resident with dement…
58y · Male·multiorgan failure due to sepsis resulting from repeatedly fractured left humeru…
Wayne Anthony Lowe, aged 58, died of multiorgan failure due to sepsis following repeated humeral fractures sustained in falls. He was admitted with a right proximal humeral fracture from an intoxicated fall, discharged a…
47y · Female·Mixed drug toxicity (venlafaxine, duloxetine, mirtazapine, oxycodone, tapentadol…
Kim Bartolo, a 47-year-old woman with depression, anxiety, alcohol use disorder and chronic conditions, died from mixed drug toxicity involving multiple prescription medications. She was admitted to Brunswick Private Hos…
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