138 results
46y · Male·Hypoxic ischaemic brain injury complicating a cardiac arrest during anaesthetic …
A 46-year-old male underwent elective inguinal hernia repair at a private hospital. During anaesthetic induction, he experienced cardiac arrest. The endotracheal tube (ETT) was visualized passing through the vocal cords,…
45y · Male·Aspiration of food bolus, with cerebral palsy as contributing factor
Stuart Wills, a 45-year-old man with cerebral palsy and severe dysphagia, died from aspiration of a food bolus while receiving meal assistance at a supported accommodation facility. Prior to his death, a speech pathologi…
Bearham: hypoxic brain injury from hanging; Fisher: asphyxiation from hanging by…
Four inpatient suicides occurred at The Canberra Hospital mental health units between January 2015 and November 2016: three by hanging and one by jumping. The coroner found systemic failures including inadequate ligature…
79y · Male·Displaced cervical vertebral fracture with secondary carotid artery dissection r…
A 79-year-old man suffered a catastrophic fall from a 3.5-metre ladder while performing home maintenance work on his property. He had recovered from a stroke three months prior, which may have affected his cognitive func…
54y · Male·Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking
A 54-year-old man with paranoid schizophrenia died of hypoxic-ischaemic brain injury from choking on food whilst in seclusion in a psychiatric intensive care unit. Key failures included: unsupervised provision of food to…
92y · Female·Complications of a fractured left femur (operated), sustained in a fall
Dorothy Lorraine Boyle, aged 92, died from complications of a left femoral fracture sustained in a fall at an aged care facility. She fell while attempting to push out a wandering dementia-affected resident who had enter…
81y · Female·Complications of choking on a food bolus in a woman with dementia
Dorothy May Nelson, an 81-year-old woman with dementia, died from complications of choking on a food bolus at an aged care facility. She was served diced beef in casserole (approximately 4cm bolus found at autopsy, despi…
66y · Male·hepatic failure, intrahepatic sepsis and intrahepatic haematoma secondary to com…
William Ernest Pears died from hepatic failure, intrahepatic sepsis and haematoma following a laparoscopic cholecystectomy in 2012. During surgery for gallstone disease, the right hepatic duct was damaged and repaired, b…
45y · Male·Global cerebral hypoxia following cardio-respiratory collapse due to anaphylaxis…
A 45-year-old man with poorly controlled diabetes, ischaemic heart disease, and recurrent lower limb infections died from anaphylaxis to intravenously administered flucloxacillin. He presented with sepsis secondary to a …
65y · Male·ischaemic heart disease following complications of colorectal surgery
A 65-year-old man with significant comorbidities (cardiomyopathy, diabetes, obesity) underwent colorectal surgery for adenocarcinoma. Post-operative course was complicated by anastomotic breakdown causing sepsis on day 1…
[18, 21, 23, 19, 22, 19]y · ["male", "female", "male", "male", "male", "female"]·MDMA toxicity (one case mixed MDMA and cocaine toxicity)
This inquest examined six deaths from MDMA toxicity after electronic dance music festivals in NSW between December 2017 and January 2019: Hoang Nathan Tran (18), Diana Nguyen (21), Joseph Pham (23), Callum Brosnan (19), …
71y · Female·pneumonia following cervical spine fracture sustained in motor vehicle collision
Julie Anne Holmes, aged 71, died of pneumonia following a cervical spine fracture sustained in a motor vehicle accident that was not diagnosed during her hospital admission. Critical clinical lessons include: (1) paramed…
8y · Female·complications of multiple injuries sustained in motor vehicle crash
Eight-year-old Anita Board died from catastrophic brain injury sustained in a motor vehicle crash at Perth Motorplex on her first junior drag racing licensing attempt. Her dragster failed to slow adequately after the fin…
53y · Female·multiple organ failure as a result of septic shock
Pauline Kessell, aged 53, died from septic shock caused by overwhelming sepsis following endoscopic pyeloscopy with laser lithotripsy for a 5cm infected staghorn calculus on 12 August 2015. Critical clinical lessons: (1)…
59y · Male·ischaemic heart disease in the context of acute-on-chronic kidney failure associ…
Arthur James Bonney, a 59-year-old prisoner with advanced cardiac disease, chronic kidney disease, and diabetes, underwent a CT scan with iodinated contrast on 30 July 2015 at Fiona Stanley Hospital. Critical failures oc…
43y · Male·hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic …
Jay Alan Paterson, a 43-year-old man with chronic pain and opioid dependence, died from hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic upper airway injury. He obtained 296 oxycodone table…
55y · Male·positional asphyxia, with sedation as an underlying risk factor
Kevin O'Halloran, a 55-year-old with chronic schizophrenia, presented with acute severe behavioural disturbance related to medication changes and possible substance use. He received substantial intravenous sedation (75mg…
58y · Female·lymphangitic carcinomatosis leading to hypoxaemic respiratory failure and cardia…
June Nutter, a 58-year-old woman presenting with weight loss, anorexia, and unexplained shortness of breath, underwent gastroscopy and colonoscopy at a private hospital to investigate suspected gastric pathology. She had…
34y · Female·Complications of fall with fractured ankle and subsequent deep venous thrombosis…
Anna Bowditch, aged 34, died from complications of deep venous thrombosis (DVT) with pulmonary embolism and paradoxical stroke following elective fracture repair surgery. She had multiple known DVT risk factors: immobili…
43y · Female·cardiac arrhythmia (unascertained), probably fatal cardiac dysrhythmia
A 43-year-old woman collapsed at home and was found in cardiac arrest after 20-25 minutes. Ambulance arrived and recognised ventricular fibrillation but failed to defibrillate for approximately 20 minutes, despite protoc…
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