Coronial

13 results for blood product transfusion

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 surger…

surgeryvascular surgerycommunicationsystemdalteparin
QLDhospitalPodcast2008-10-10

Maxfield, Annette

62y · Female·Haemorrhage caused by abdominoperineal excision of the rectum

…rous and unnecessary. When massive haemorrhage occurred, management was delayed by inadequate preoperative blood work, blood product availability, and failure of the anaesthetist to order critical tests promptly. The co…

colorectal surgeryanaesthesiadiagnosticproceduralsevoflurane
NSWhospital2023-03-20

Inquest into the death of Heather Winchester - Decision

Female·Not definitively stated in judgment; death followed complications from initial s…

…tember 2019. The core issue was whether the inquest should examine the nature and extent of her consent to blood products, given her religious objections to transfusions. The Deputy State Coroner ruled that inquiry into…

general surgerygynaecologycommunicationsystem
WAhospital2012-03

Inquest into the Death of Troy

63y · Female·Intra-cerebral bleed secondary to thrombocytopenia in a person with prolymphocyt…

…elet delivery procedures. Several recommendations were made to improve communication, patient records, and blood product access for regional hospitals.

haematologyintensive carecommunicationdelaychemotherapy
NSWhospital2025-02-28

Inquest into the death of Heather Winchester

75y · Female·multiple organ failure due to severe anaemia secondary to blood loss post electi…

…ccurred: the surgical and anaesthetic teams held conflicting understandings about whether she would accept blood transfusion—the surgeon believed she refused all blood products based on her consent form and Jehovah's Wi…

gynaecologyanaesthesiacommunicationsystem
QLDhospital2016-02-29

Mr B - Non-inquest findings

84y · Male·Acute myocardial infarction precipitated by upper gastrointestinal haemorrhage f…

…s prescribed rivaroxaban for deep vein thrombosis despite being a practicing Jehovah's Witness who refused blood transfusions. Rivaroxaban cannot be monitored or reversed, unlike warfarin. He developed upper gastrointes…

cardiologyhaematologymedicationcommunicationrivaroxaban
ACThospital2024-09-11

Inquest Into The Death Of Baby X

0y · Male·Hypoxic-ischemic encephalopathy and massive subgaleal haemorrhage, both associat…

… despite visible scalp bruising from 27 minutes after birth. Delayed recognition deprived Baby X of timely blood product transfusions and contraindicated cooling therapy was inappropriately continued. CHS has since impl…

obstetricsneonatologydiagnosticcommunication
NSWcommunity2020-01-24

Into the death of Thomas Redman

18y · Male·Incised wound to right axilla with complete transection of basilic vein, brachia…

…pilot's perspective on weather constraints not directly included in the clinical teleconference; (3) whole blood and clotting factors availability in rural hospitals remains critically inadequate; and (4) protocols for …

emergency medicinetrauma surgerycommunicationsystemoxygen
WAhospital- 27 May 2014

Inquest into the Death of Julissa Teresa GILBERT

57y · Female·Intra-abdominal Haemorrhage following Appendectomy, with contributing factor of …

… failures included: incomplete handover between anaesthetist and post-operative team; misinterpretation of blood gas analysis; failure to involve the surgeon when post-operative deterioration was apparent; and absence o…

anaesthesiasurgerydiagnosticcommunicationaramine
NSW2025-03-25

Inquest into the death of Bernard Greenwell

84y · Male·haemoperitoneum due to ruptured abdominal aortic aneurysm

Bernard Greenwell, an 84-year-old male, died from rupture of an abdominal aortic aneurysm (AAA) while in custody at Cessnock Correctional Centre. He experienced sudden-onset severe left groin pain at 11:30am on 25 April …

emergency medicinevascular surgery
VIChospital2026-03-25

Finding into death of JNL (Jeremy)

14y · Male·Retroperitoneal haemorrhage secondary to abdominal injuries sustained in a motor…

A 14-year-old boy riding an illegally high-powered e-scooter (capable of 40-50 km/h) collided with a utility vehicle at a residential intersection. The e-scooter exceeded legal speed limits and age restrictions under Vic…

emergency medicinetrauma surgery
VIChospital2026-01-08

Finding into death of Malakai Cross-De Jesus

0y · Male·Complications following forceps delivery

…, improve situational awareness in neonatal resuscitation, and develop statewide guidelines for massive transfusion in neonates.

obstetricsneonatologydiagnosticcommunicationbenzylpenicillin
VIChospital2018-10-05

Finding into death of Mrs Z

70y · Female·Tiger snake envenomation

Mrs Z, a 70-year-old woman, died from tiger snake envenomation after being bitten on the left foot while sleeping. She received two vials of antivenom within 2.5–4 hours of the bite at Royal Melbourne Hospital, consisten…

toxicologyemergency medicinediagnosticcsl tiger snake antivenom

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