15 results
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…
78y · Female·cardiorespiratory failure, ischaemic and hypertensive heart disease together wit…
Barbara Francis, a 78-year-old resident with dementia at Pearl Supported Care in the dementia unit (Dinah), was punched by another resident (Mr A) on 4 September 2018 and fell backward onto her right hip, sustaining an o…
62y · Male·hepatic encephalopathy due to acute renal failure
Ronnie Pangata Nelson, a 62-year-old Aboriginal man, died in Alice Springs Hospital from hepatic encephalopathy due to acute renal failure. He had longstanding chronic diseases including cirrhosis, hepatitis B and C, dia…
7y · Female·respiratory failure from severe scoliosis due to Murray Valley encephalitis
Ruby Blitner died from respiratory failure secondary to severe scoliosis caused by Murray Valley encephalitis acquired at age two. Her clinical course involved progressive respiratory compromise, recurrent aspiration pne…
43y · Female·acute multiple drug toxicity on a background of chronic pain and morbid obesity
A 43-year-old woman died from acute multiple drug toxicity after 26 years of high-dose opioid therapy for chronic pain following a motor vehicle accident. Despite recognition by multiple clinicians that opioid doses exce…
53y · Male·Drowning
Paul James Du Toit, 53, died by drowning after sustaining severe pelvic injuries at Stingray Head Beach on 20-21 March 2012. While intoxicated, he exited a vehicle during a night-time beach drive in darkness and fell fro…
12y · Female·acute septicaemia resulting from osteomyelitis of the left femur
A 12-year-old Aboriginal girl died from septicaemia caused by untreated osteomyelitis of the left femur. Three weeks after a sports injury, despite evidence of severe and deteriorating illness including inability to walk…
82y · Female·acute peritonitis, ruptured bowel and incarcerated bowel herniation
An 82-year-old woman admitted with bowel obstruction recovered well initially but suffered a preventable fall in the radiology department when left unattended with heavy IV pumps on her wheelchair, fracturing her hip. Af…
29y · Male·Blunt head and neck injuries sustained in an unintentional motor vehicle acciden…
A 29-year-old man sustained severe blunt head and cervical spinal cord injuries in a motor vehicle accident. He remained unconscious with high intracranial pressure and C5 spinal cord transection. After 12 days with no i…
57y · Female·acute pulmonary embolism
Sandra McRae, age 57, died from pulmonary embolism on day 13 of hospitalisation following pelvic fractures sustained in a motor vehicle accident. The coroner found the death was potentially preventable due to failure to …
28y · Male·hypovolemia secondary to haemorrhage from operative exploration of multiple stab…
A 28-year-old Aboriginal male died from hypovolemic shock following operative exploration of multiple stab wounds to the thigh. The death was preventable. Critical failures included: delayed surgery from Friday to Saturd…
31y · Female·Septicaemia following Acute Osteomyelitis following Fractures of the Left Leg
Isabelle Manyita, a 31-year-old Aboriginal woman, died from septicaemia following acute osteomyelitis complicating fractures of her left leg. She presented to Royal Darwin Hospital on 22 April 2005 with a tibial and fibu…
67y · Male·undetermined; likely exposure and dehydration
David William Mather, a 67-year-old homeless man, was admitted to Royal Darwin Hospital on 29 September 2003 with a displaced compound fracture of the left humerus. He left the ward on 4 October 2003 in hospital pyjamas,…
10y · Male·Septic arthritis of the left shoulder with acute heart failure resulting from to…
Sebastian Barry Davis, aged 10, died from septic arthritis of the left shoulder resulting in acute heart failure. He had congenital sensory neuropathy with anhidrosis from birth, causing inability to sweat and lack of pa…
25y · Male·positional asphyxia in a man with extensive old hypoxic brain damage, acute ches…
Corey Paddy, a 25-year-old Aboriginal man with severe hypoxic brain injury from a 1998 car accident, died at Katherine Hospital from positional asphyxia while receiving concurrent morphine therapy and suffering from acut…
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