228 results for “airway management”
23y · Male·aspiration of blood due to stab wound to trachea
…as discharged again. Collapsed later that day with massive haemorrhage from trachea, aspirating blood into airway. Died from aspiration. Autopsy showed 2.5cm deep tracheal penetration. Expert review identified that penet…
15y · Female·Seizure disorder (epilepsy) with associated vomit aspiration; Sudden Unexpected …
A 15-year-old girl with refractory epilepsy and intellectual disability died from a seizure with vomit aspiration at a special needs holiday camp on the second night of attendance. She had known epilepsy managed with mul…
29y · Male·acute asthma
…ventable factors included suboptimal preventer use, lack of lung function testing, and absence of asthma management plans among the cohort.
14y · Female·Hypoxic-ischaemic encephalopathy due to choking on food, as a consequence of foe…
A 14-year-old girl with foetal alcohol syndrome, autism, and intellectual impairment died from hypoxic-ischaemic encephalopathy following choking on food during a community outing. She had been in state care since infanc…
Unknown·Ms Choi: hypoxic brain damage due to drowning/immersion due to rafting accident;…
…ined 'river etiquette' rather than documented procedures. Guides had different understandings of traffic management at the rapid. The coroner recommended formal rapid-by-rapid risk assessments identifying collision hazar…
38y · Female·Drowning/Immersion due to coronary artery atheroma
Leila Michelle Trott, a 38-year-old experienced skipper and dive instructor, drowned after swimming approximately 400 metres to retrieve a drifted tender vessel off Green Island, Cairns. Unbeknownst to her, she had sever…
33y · Male·sharp force injuries of the neck
Malcolm Brown, a 33-year-old Aboriginal man with a history of methamphetamine use, mental health crisis, and self-harm threats, died from sharp force injuries to his neck on 29 June 2022 following a NSW Police operation.…
42y · Female·Hypoxic brain injury due to choking on food, with Cornelia de Lange Syndrome con…
…ndations, and recognizing that genetic conditions causing dysphagia require constant, not episodic, risk management.
6y · Male·Global cerebral ischaemia secondary to perinatal asphyxia
…ek prior; (2) the abnormal CTG at 9:30pm required either fetal blood sampling or expedited delivery, but management was delayed approximately 1.5 hours; (3) communication failures with a CALD patient without interpreter …
18y · Female·Generalised tonic-clonic seizure and cardiac arrest arising from severe hyperten…
An 18-year-old pregnant woman presented in labour at 41 weeks and 2 days gestation. From 23 September onwards, she experienced intermittent headaches, epigastric pain, proteinuria and peripheral oedema. At 1755 hours on …
3y · Male·asphyxia secondary to epilepsy
… detailed recommendations to improve procedures, documentation of medical conditions, and development of management plans in consultation with parents and treating doctors.
23y · Male·combined drug toxicity (methadone, clozapine, quetiapine, diazepam, chlorpromazi…
Geoffrey Reid, 23, died from combined drug toxicity while hospitalised for schizophrenia management. He was re-inducted onto methadone at 30mg with 10mg daily increments to 50mg over four days, escalated …
Multiple penetrating knife wounds with hemorrhagic shock and traumatic cardiac a…
…n others at Westfield Bondi Junction shopping centre in Sydney. The coroner found Cauchi's mental health management deficient, particularly regarding cessation of antipsychotic medication without appropriate ongoing moni…
31y · Male·positional asphyxia due to synthetic cannabis use and obesity
…ecurity methods (dogs, standard drug tests), and its known dangers were not adequately addressed. Prison management failed to respond to recognized escalating Kronic use despite awareness of intoxication incidents. Criti…
43y · Female·acute multiple drug toxicity on a background of chronic pain and morbid obesity
…ctually increased following hip replacement surgery. Key clinical failures included: lack of coordinated management plan between specialists and general practitioners; failure to detect prescription shopping when patient…
83y · Female·Aspiration bronchopneumonia in a setting of cerebral infarction
Ms Patricia Grant, 83, died from aspiration bronchopneumonia following cerebral infarction while living with her son and daughter-in-law. She experienced severe neglect and elder abuse in her final years: cessation of ep…
57y · Female·Positional asphyxia caused by the combined effect of consumption of several opia…
57-year-old woman with chronic pain died from positional asphyxia caused by consumption of multiple sedative medications. She was prescribed opioids (Fentanyl, Oxycodone) and Pregabalin, but also obtained Dolased and Pro…
36y · Female·Pneumonia complicating combined drug effect
Vicki Anne Greaves, 36, died on 18 March 2004 at Royal Perth Hospital Emergency Department from pneumonia complicating combined drug effect. She was subject to an Intensive Supervision Order for drug-related offences. On…
39y · Female·Septic shock and nosocomial pneumonia secondary to pentobarbital (Nembutal) over…
…een respecting patient confidentiality and involving supportive family members in care planning and risk management; (3) the limitations of Community Treatment Orders for patients with severe personality pathology and mi…
33y · Male·cardiorespiratory arrest during restraint, involving a predisposition to cardiac…
33-year-old Indigenous man died following police restraint and inappropriate midazolam administration during an acute drug-induced behavioural disturbance. Mr Coolwell sustained injuries while in acute methamphetamine-in…
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