Coronial

11 results for blood gas sampling

NSWhospital2023-05-09

Inquest into the death of Harriet Ostler

1y · Female·sudden cardiac death on a background of rhinovirus infection

…s (respiratory rate >70, elevated heart rate) as requiring escalation despite fever; (3) the importance of blood gas sampling when vital signs deteriorate; (4) implementing Between the Flags vital sign monitoring system…

paediatricsemergency medicinediagnosticcommunicationsalbutamol
VIChospital2023-10-20

Finding into death of Vanessa Li

0y · Female·subgaleal haematoma complicating an obstructed labour

…SGH was not identified until 7.30am, approximately 6 hours after birth. Earlier recognition and aggressive blood pressure support may have prevented deterioration, though outcome was likely poor. Key lessons: always com…

obstetricsneonatologycommunicationdiagnosticoxytocin
VIChospital2016-06-21

Finding into death of Summer Jamsek

0y · Female·Persistent pulmonary hypertension in the newborn (PPHN)

…al. The coroner found Baby Summer died from PPHN but was not satisfied it was caused by sepsis despite low blood sugars and fluctuating oxygen requirements. While Dr M.'s management was generally appropriate, the corone…

obstetricspaediatricsdelayescitalopram
SAhospital2021-11-23

Coroner's Finding: Osborne, Brian Thomas

89y · Male·combined effects of cerebrovascular accident, pneumonia and chronic cardiac fail…

An 89-year-old man with multiple comorbidities (ischaemic heart disease, diabetes, COPD) presented with chest infection and was admitted for heart failure. He suffered an acute stroke with subsequent delirium and combati…

cardiologyneurologyinsulin
NSWhospital2023-08-22

Inquest into the death of AN

0y · Female·Methylamphetamine toxicity

A newborn baby died 8 hours after birth from methylamphetamine toxicity acquired in utero. The mother unknowingly consumed methylamphetamine in the days before labour, likely by drinking from a contaminated bottle at a r…

neonatologypaediatricsmethamphetamine
VIChospital2026-01-23

Finding into death of Trang Thi Thu Le

28y · Female·3,4-methylenedioxy-N-methylamphetamine (MDMA) and ketamine toxicity

Trang Thi Thu Le, 28, died on her birthday from MDMA and ketamine toxicity after attending an electronic dance music event at John Cain Arena. She collapsed after consuming drugs purchased from an unknown source within t…

emergency medicineintensive caresystemMDMA
VIChospital2025-02-20

Finding into death of Mia Rose Iskander

0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the sett…

…dditional delays occurred between decision (2:02 pm) and theatre commencement (3:31 pm) due to waiting for blood results and fasting confirmation, and a junior doctor was permitted to attempt spinal anaesthesia during a…

obstetricsneonatologydiagnosticdelayamoxicillin
VICaged care2020-10-22

Finding into death of Phillip Harry Parker

61y · Male·Pneumonia

A 61-year-old man with significant medical complexity including acquired brain injury, bronchiectasis, pulmonary fibrosis, and dysphagia died from pneumonia 26 days after receiving another resident's slow-release opioid …

geriatric medicineemergency medicinemedicationsystemtapentadol sr
NSWhospital2026-03-19

Inquest into the death of Eve Brown

42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…

Eve Brown, a 42-year-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ri…

emergency medicinegeneral practicediagnosticcommunicationceftriaxone
QLDhospital2024-06-21

Non-inquest findings into the death of Mr K

81y · Male·Chronic lung disease (severe COPD) with atherosclerotic cardiovascular and valvu…

An 81-year-old man with severe COPD died following inappropriate interhospital transfer to a private hospital and subsequent management errors. Key clinical lessons: (1) patients with CO2 retention require explicit ident…

respiratory medicineemergency medicinemedicationcommunicationdiazepam
WAhospital2023-02-22

Inquest into the Death of Aishwarya Aswath CHAVITTUPARA

7y · Female·multiorgan failure due to fulminant sepsis (Streptococcus pyogenes)

…genes) after approximately 90 minutes in Perth Children's Hospital emergency department. She presented with gastrointestinal symptoms, fever, cold extremities and lethargy but was triaged as low-acuity (category 4). Cri…

emergency medicinepaediatricsdiagnosticcommunication

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.