Coronial
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SAhospital2003-03-12

Coroner's Finding: STOLL Ruth Sophie

71y · Female·massive acute haemolysis leading to severe anaemia and multi-system failure as a…

Ruth Stoll, 71, died from massive acute haemolysis and multi-system failure after receiving incompatible blood transfusions during aortic aneurysm repair. Pre-operative blood samples from Stoll and another patient (Koven…

cardiothoracic surgeryanaesthesiadiagnosticprocedural
VIChospital2003-02-01

AINALIDIS Taylor

0y · Male·Cardiorespiratory failure due to failure of anaesthetic rebreathe bag

Taylor Ainalidis, aged 3 weeks, died on 21 June 2000 at the Royal Children's Hospital following cardiorespiratory failure during resuscitation after surgery for Tetralogy of Fallot. The primary cause was failure of an an…

cardiothoracic surgeryanaesthesiasystemprocedural
SAhospital2002-02-28

Coroner's Finding: GALEA Lesley Anne

30y · Female·respiratory failure related to bronchopneumonia following cerebral anoxia due to…

A 30-year-old woman with a previous caesarean section attempted a trial of vaginal delivery. She received Syntocinon augmentation at 6:45 AM without prior cervical assessment and epidural analgesia at 7:35 AM. No vaginal…

obstetricsanaesthesiadiagnosticcommunicationoxytocin
SAhospital2001-11-08

Coroner's Finding: STEWART Margaret May

77y · Female·multi-organ failure due to massive transfusion-induced coagulopathy following re…

A 77-year-old woman died from multi-organ failure following massive transfusion-induced coagulopathy after a retroperitoneal haemorrhage of unknown origin post-knee replacement surgery. While Fragmin anticoagulation was …

surgeryvascular surgerycommunicationsystemdalteparin
SAhospital2001-09-07

Coroner's Finding: SANDS Celia Laurel

82y · Female·peritonitis due to a perforated viscus (proximal jejunum) resulting from motor v…

An 82-year-old woman suffered a motor vehicle accident causing blunt abdominal trauma. Despite initial clinical assessment appearing adequate, a perforated jejunum with developing peritonitis was not diagnosed until earl…

general surgeryemergency medicinediagnosticdelay
NThospital2000-10-31

Inquest into the death of Corey Paddy

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…

orthopaedic surgeryneurologycommunicationsystemmorphine
SAhospital2000-07-21

Coroner's Finding: DRESCHLER Michelle Lee

27y · Female·Aspiration of gastric contents associated with persistent vomiting following gas…

A 27-year-old woman died from aspiration of gastric contents following a vertical-banded gastroplasty performed for morbid obesity. The surgeon created a stoma (opening) of 4-5mm diameter using a 27 French bougie, smalle…

general surgerygeneral practiceproceduralcommunicationdiazepam
WAhospital

Inquest into the Death of June Valerie LOBBAN

69y · Female·Intra-abdominal sepsis and shock with multi-organ failure following intestinal p…

A 69-year-old woman died from intra-abdominal sepsis and multi-organ failure following a perforated caecum that occurred after lumbar spine surgery. Post-operatively, she developed abdominal distension and pain initially…

neurosurgerygeneral surgerydiagnosticdelayfentanyl
WAhome

Inquest into the Death of Baby AM

0y · Male·severe hypoxic ischaemic encephalopathy secondary to uterine rupture

Baby AM died from severe hypoxic ischaemic encephalopathy secondary to uterine rupture during a planned home vaginal birth after caesarean (VBAC). The mother, Ms M, was 40 weeks and 5 days pregnant, attended by a private…

obstetricsmidwiferydiagnosticcommunication

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