49y · Female·Hypoxic brain injury related to tracheostomy complications in form of airway occ…
…h 2018 with delayed diagnosis. Following complex neurosurgery causing Wallenberg syndrome, she required tracheostomy for bulbar dysfunction. On 13 June 2018, she suffered cardiorespiratory arrest due to airway occlusion …
20y · Male·anoxic brain injury following cardio-respiratory arrest caused by hypoxia result…
…0-year-old male died from anoxic brain injury following cardiac arrest caused by hypoxia resulting from tracheostomy tube occlusion. After motor vehicle trauma, he underwent surgery and was eventually transferred to a ge…
1y · Male·Global cerebral ischaemia in an infant with upper airway obstruction
NB, a 14-month-old with a tracheostomy requiring overnight nursing support in foster care, suffered a cardiac arrest on 17 December 2016 that …
52y · Female·haemorrhage from a tracheal-innominate artery fistula complicating a tracheostom…
…ed from catastrophic haemorrhage due to a tracheal-innominate artery fistula 10 days after percutaneous tracheostomy following stroke and decompressive craniectomy. Minor bleeding was observed 3 days before death. The co…
20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…
…20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged. Clinical staff per…
75y · Female·Airway obstruction due to aspiration occluding a permanent tracheostomy
Feryne Gaylene Hunter, aged 75, died from airway obstruction due to aspiration into her permanent tracheostomy. She had a history of subglottic stenosis, asthma, and gastro-oesophageal reflux disease with a hiatus …
70y · Female·Hypoxic/Ischaemic Encephalopathy consequent upon Cardiorespiratory Arrest and Co…
…air, though perforations were not initially recognized. Further surgery on 18 April managed fistulae. A tracheostomy was inserted 24 April at Prince of Wales Hospital. That evening, the tracheostomy tube became dislodged…
61y · Male·pulmonary thromboembolus
…tive complications from laryngectomy, which he complicated by refusing nasogastric feeding and adequate tracheostomy care. The coroner found no evidence of inadequate medical care, noting Fleming frequently refused offer…
50y · Male·Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (t…
A 50-year-old man died from tracheostomy site haemorrhage 36 days after laryngectomy for recurrent laryngeal cancer. He lived alone post-dischar…
49y · Female·Hypoxia due to complications following incision and drainage of a right buttock …
…ing hypoxia; medication errors (Metaraminol infusion continued, Propofol not commenced); and subsequent tracheostomy dislodgement causing further hypoxic events. The chain of preventable errors resulted in permanent brai…
84y · Male·Respiratory failure complicating hospital acquired pneumonia following surgical …
…nts with comorbidities; (2) Goals of Care discussions should occur early and be clearly documented; (3) tracheostomy decannulation in high-risk patients requires careful multidisciplinary assessment, which was undertaken…
54y · Female·Pneumonia - chest sepsis
Kim Elizabeth Taylor, a 54-year-old NDIS participant with quadriplegia and tracheostomy, died from pneumonia and chest sepsis at Austin Hospital. She had experienced recurrent ventilator-asso…
23y · Male·complications of blunt force head injuries
…d strike his head on a concrete kerb. He suffered a fractured skull and severe brain injury requiring a tracheostomy tube for respiratory support. Despite numerous life-saving medical interventions, he remained profoundl…
75y · Female·Septicaemia as a result of lobar pneumonia; congestive heart failure also presen…
A 75-year-old woman died from septicaemia following a percutaneous tracheostomy procedure performed by a locum consultant on a Sunday. The procedure deviated significantly from the es…
78y · Male·cardiorespiratory failure due to complications of tracheal stenosis
Bruce Hodges, a 78-year-old man with a 20-year-old tracheostomy following laryngeal cancer surgery, presented to hospital with progressive shortness of breath and trac…
66y · Male·respiratory infection on a background of metastatic carcinoma
…ospital from respiratory infection secondary to metastatic carcinoma. He had undergone laryngectomy and tracheostomy for throat cancer in 2017, and presented with extensive nodal involvement discovered on imaging in Dece…
70y · Male·spontaneous left frontal intracerebral haemorrhage
…respiratory arrest. Subsequent investigations revealed anterior myocardial infarction and recent CVA. A tracheostomy was performed. EEG showed diffuse hypoxic brain injury with poor prognosis. Aggressive management was c…
69y · Male·Hypoxic ischaemic brain injury secondary to right facial artery pseudoaneurysm r…
…fied under-recognition of airway threat and communication delays. New protocol now mandates pre-emptive tracheostomy for post-chemoradiotherapy oropharyngeal bleeds. Key lessons: recognise sentinel airway risk, escalate …
60y · Male·bronchopneumonia as a result of or secondary to cerebral haemorrhage; contributi…
…h pneumonia on 12 October 2004 and despite aggressive ICU management including intubation, ventilation, tracheostomy, and vasopressor support, his condition progressively deteriorated. The coroner found that correctional…
52y · Male·HIV infection complicated by basal and squamous cell carcinoma of the head and n…
…esented with severe bleeding from the mouth and was admitted to hospital where he underwent intubation, tracheostomy, and embolisation of the lingual artery. He was managed palliatively thereafter and died approximately …
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