Coronial

108 results for fluid resuscitation

TAScommunity2022-07-04

Coroner's Finding: Leighton, Garth Mcdonald

58y · Male·chest and abdominal injuries sustained in motor vehicle collision

…hree doctors present at the scene. Critical management issue: when a qualified doctor (Dr H.) requested IV fluids for fluid resuscitation to manage hypovolaemic shock from severe trauma, the volunteer ambulance had none…

emergency medicinesurgerysystemdelay
NSWcommunity2020-03-03

Inquest into the death of Scott CAYIRYLIS

45y · Male·cardiac arrest due to profound blood loss causing hypovolaemia

…s would have arrived much earlier when the patient would 'more than likely have survived' with intravenous fluid resuscitation. Key lessons: ensure accurate understanding of dispatch protocols among all staff; prevent m…

emergency medicineparamedicinesystemcommunication
NT2017-10-13

Inquest into the death of John Roberts

37y · Male·water intoxication and olanzapine toxicity in association with schizophrenia

…n of psychogenic polydipsia (excessive water drinking), not yet well-recognised in custodial settings. Resuscitation attempts were hampered by excessive pulmonary fluid. The coroner found no causative failures in medica…

psychiatryemergency medicineolanzapine
NSWcommunity2016-01-29

Jimmy JAMES - Findings

44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)

…tical sepsis indicator—the result was not communicated to or acted upon by treating physicians. Inadequate fluid resuscitation, failure to escalate to ICU promptly, incomplete antibiotic therapy, and poor clinical hando…

emergency medicineintensive carediagnosticmedicationceftriaxone
VIChospital2013-09-17

Finding into death of Mary Anna Powlina Korzeniewski

37y · Female·Hypoxic brain injury complicating cardiorespiratory arrest during manual removal…

…atient suffered sudden cardiorespiratory arrest with profound ST changes and ventricular fibrillation. Resuscitation was prolonged; she regained output but sustained irreversible hypoxic brain injury and died three days…

obstetricsanaesthesiacommunicationoxytocin
TAShospital2023-11-17

Coroner's Finding: Williams, Stewart

54y · Male·Hypoxic/ischaemic brain damage caused by blood loss and airway obstruction due t…

…enior clinician involvement despite ongoing bleeding despite packing and initial interventions; inadequate fluid balance documentation leading to underestimation of blood loss (500ml initially unrecorded); delayed invol…

emergency medicineoral and maxillofacial surgerydiagnosticcommunication
SAhospital2006-05-19

Coroner's Finding: FALANGA Salvatore

77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…

…al function occurred. Key clinical lessons: (1) recognition of hypovolaemic shock required more aggressive fluid resuscitation earlier; (2) senior clinician review warranted overnight given complexity and high-risk como…

cardiologycardiothoracic surgerydiagnosticproceduralramipril
SAhospital2021-06-30

Coroner's Finding: MOKETARINJA Anthea Ryder

42y · Female·multiple organ failure due to sepsis on a background of pneumonia, spontaneous b…

… worsening encephalopathy and sepsis. Multiple MET calls occurred on 30-31 July with hypotension requiring fluid resuscitation. A multidisciplinary team deemed intensive care inappropriate given her terminal condition a…

general medicinepsychiatryantibiotics
VIChospital2025-08-13

Finding into death of Jordan Thomas Alexander McDonald

0y · Male·complications of extreme prematurity in the setting of precipitant premature bre…

…ent following precipitant breech labour with a circumvallate placenta. He received appropriate initial resuscitation but was administered 10 times the prescribed morphine dose due to calculation error during a time-crit…

neonatologyobstetricsmedicationdiagnosticmorphine
VICaged care2011-06-06

Finding into death of John Bateman

76y · Male·Complications following surgery for intradural cervical meningioma

…orated, requiring transfer to coronary care. He developed complications including hydrocephalus and spinal fluid infection, leading to insertion of a stent in September. By October, with ongoing health decline, he was t…

neurosurgerypalliative care
VIChospital2012-10-26

Finding into death of Rodney David Keegan

41y · Male·Cardiomyopathy in a setting of acute abdomen

…or cardiac surgery, was admitted to hospital following a fall. He developed acute abdominal pain with free fluid on imaging but no identifiable cause. He suffered cardiopulmonary arrest, was resuscitated and intubated b…

cardiologyintensive carewarfarin
QLD2014-12-12

Chen, Ruby Yan

3y · Female·massive air embolism

… giving set, allowing air to enter the bag. The bag was placed in an opaque pressure cuff that forced both fluid and air through the IV line into the patient's circulation. At 250 mL/hour infusion rate, fluid exhausted …

retrieval medicineemergency medicineproceduralsystem
QLDhospital2023-08-17

Schwartz, Thomas Edward

64y · Male·End stage liver disease due to Hepatitis C and non-alcoholic fatty liver disease

…ver disease was managed by specialist teams with frequent hospital admissions over two years. An Acute Resuscitation Plan was established reflecting his wishes. The coroner concluded the death was from natural causes wi…

gastroenterologyhepatologyoxazepam
QLDhospital2010-06-11

Whiting, Edith

68y · Female·Anaphylactoid reaction to intravenous CT scan contrast medium leading to cardior…

…st injection triggered a severe anaphylactoid reaction with bronchospasm and cardiorespiratory arrest. Resuscitation was suboptimal: adrenaline administration was delayed when it should have been given immediately as th…

emergency medicinesurgerycommunicationdelayintravenous contrast medium
WAhospital2016-05-20

Inquest into the death of Sebastian Keith PARMAN

6y · Male·pneumonia complicating influenza A (H1N1) infection with secondary streptococcal…

… documented tachycardia (pulse 184-192) and tachypnoea, and his provision of maintenance rather than bolus fluids. The child deteriorated to cardiopulmonary arrest on 17 September. Expert evidence indicated that with ap…

emergency medicinepaediatricsdiagnosticcommunicationpenicillin
QLDPodcast2020-01-24

Willersdorf, Maria

87y · Female·Hypoxic-ischaemic encephalopathy secondary to cardiac arrest, with valvular hear…

…. The treating radiologist failed to recognize the seriousness of her deterioration, provided only minimal fluid resuscitation (50ml saline), left her without adequate supervision, and did not initiate resuscitation des…

radiologypain medicinediagnosticproceduralbupivacaine
SAhospital2002-02-28

Coroner's Finding: GALEA Lesley Anne

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

…. Continuous electronic fetal monitoring was delayed until 8:00 AM. She collapsed at 9:30 AM with amniotic fluid embolism following uterine rupture, suffering catastrophic cerebral hypoxia, cardiac arrest, coagulopathy,…

obstetricsanaesthesiadiagnosticcommunicationoxytocin
VIChospital2012-07-16

Finding into death of Dishita Madamshetty

0y · Female·Hypoxic brain injury in the setting of meconium aspiration syndrome and chorioam…

…oamnionitis. The baby presented in poor condition at delivery with thick meconium present and required resuscitation. Critical clinical lessons include: (1) inadequate CTG monitoring before induction—the abnormal trace …

obstetricsneonatologydiagnosticcommunication
VIChospital2021-11-18

Finding into death of Pippa May Griffiths

0y · Female·Neonatal death in the setting of meconium aspiration

…vious day with decreased foetal movements and was discharged without comprehensive assessment (no amniotic fluid index measurement). Critically, the admission midwife on labour was unaware of this history, so did not pe…

obstetricsmidwiferycommunicationdiagnosticbenzyl penicillin
SAhospital2001-09-04

Coroner's Finding: CHESTER George Spencer

18y · Male·multiple injuries

… assessment and early airway management; recognition that massive transfusion protocols and aggressive resuscitation were required. The coroner found no clinical error in hospital management, but noted that the deceased…

emergency medicinetrauma surgery

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