Coronial — Australian Coroners Findings

State

WANSWVIC2QLDSATASACTNT

Setting

hospital2aged caremental healthcommunityhomeother

Hospital

Sunshine Hospital1Monash Medical Centre1

Specialty

paediatrics2anaesthesia2retrieval medicine1radiology1pathology1paediatric surgery1obstetrics1neonatology1

Error Type

diagnostic2medicationprocedural1communication1system2delay1

Preventability

PreventablePossibly preventable2Not preventableNot stated

Age Group

AdultPaediatric1Neonate1

Sex

MaleFemale2

Clinical Flags

Escalation failure1AHPRA referral madeRural / remotePrison / police custodyAged care deathMental Health Act involvedFamily violence relatedHas recommendations2

Year Range

–

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VIChospital2017-01-24

Finding into death of Baby XY

0y · Female·Perinatal asphyxia

Baby XY, a 41-week-old newborn, died from perinatal asphyxia six hours after birth at Sunshine Hospital. The primary clinical lesson involves diagnostic failure: the mother was not diagnosed with gestational diabetes dur…

anaesthesiaforensic medicinediagnosticsystembenzyl penicillin

VIChospital2011

Finding into death of ALYSSA TZE SIM CHAN

Female·Combination of liver failure, blood loss and shock following needle biopsy

Alyssa, a 9-week-old infant, died from hemorrhage following a liver biopsy at Monash Medical Centre. She had persistent jaundice, and biopsy was undertaken to investigate potential biliary atresia. Post-operatively, nurs…

gastroenterologyanaesthesiadiagnosticproceduralphytomenadione

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