13 results
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…
47y · Female·Overdose of hydromorphone
A 47-year-old woman died from an intentional overdose of prescribed hydromorphone while residing at a domestic violence refuge. She had a history of depression, previous suicide attempts, and was in crisis following sepa…
28y · Male·Mixed drug toxicity (synergistic effects of diazepam, oxycodone, and fentanyl ca…
Matthew McLachlan, a 28-year-old paraplegic with chronic pain from spinal cord injury, died from mixed drug toxicity while hospitalized for urinary tract infection treatment. He was receiving fentanyl patches, oxycodone,…
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…
33y · Male·Opiate toxicity
A 33-year-old man with previously unrecognized obstructive sleep apnoea was admitted with severe headache. The treating physician prescribed a complex regimen of escalating opiate doses including both slow-release (MS Co…
53y · Male·Self-inflicted gunshot wound to the head
Leslie Winbank, a 53-year-old man with chronic pain from disc prolapse and prostate cancer, died from a self-inflicted gunshot wound during a police siege at his home. He had a family relationship breakdown and was on pa…
22y · Male·mixed drug toxicity due to methadone, codeine, and morphine (metabolite), compou…
William Wallrock, 22, died from mixed drug toxicity four days after wisdom tooth extraction. He was initially appropriately advised to use paracetamol and ibuprofen. When inadequate pain relief prompted him to seek furth…
45y · Male·Hypoxic-ischaemic encephalopathy due to prolonged hypoxia
A 45-year-old man died from hypoxic-ischaemic encephalopathy following cardiopulmonary arrest 11 hours after elective wrist plate removal surgery. Multiple contributing factors were identified: undisclosed obstructive sl…
37y · Female·exsanguination from incised wounds to right wrist and elbow
Tracey Inglis, a 37-year-old woman with chronic pain from multiple orthopaedic injuries, hepatitis C, and a history of suicidal ideation, died by suicide while imprisoned. Critical clinical lessons include: the Initial R…
60y · Male·Hypertensive heart disease with chronic fatty liver as other significant conditi…
David Duggan, a 60-year-old man with hypertensive heart disease and cardiomegaly, was admitted to Caloundra Hospital on 10 January 2007 for management of severe acute back pain caused by a suspected L3/4 disc herniation …
66y · Male·Coronary atherosclerosis
Frank Maurice Whittington, aged 66, died from coronary atherosclerosis on 24 February 2004, shortly after day surgery to replace a catheter on his intrathecal morphine pump. Dr R. and RN Couper administered a 0.26ml over…
48y · Male·Undetermined
Maxwell Marshall, aged 48, died in December 2003 from undetermined causes after receiving escalating doses of oxycodone (Oxycontin) for post-Guillain-Barré neuropathic pain reaching 680mg daily—among the highest 1% of pr…
76y · Male·morphine toxicity and carcinomatosis
John Walter Hedges, a 76-year-old man with terminal metastatic cancer, died at Greenslopes Private Hospital following a morphine overdose administered by agency nurse Cornelia Empen. Hedges had two pain management routes…
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