329 results for “delivery”
0y · Female·Sudden Infant Death Syndrome (SIDS Category II)
A 3-month-old female infant died from Sudden Infant Death Syndrome (SIDS Category II) after co-sleeping with her parents. The death occurred in the context of unsafe sleeping practices despite prior intervention by Child…
0y · Male·cardiogenic shock and neonatal encephalopathy
Matthew Hutchinson, born at 1 day of age at Flinders Medical Centre, died from cardiogenic shock and neonatal encephalopathy. While obstetric care was appropriate, neonatal care was significantly deficient. Critical fail…
26y · Female·Toxicity to Pentobarbitone
…issued to select appropriate tests. While the coroner could not definitively state that preventing parcel delivery would have prevented death (given Dannika's multiple suicide plans), improved customs communication repre…
81y · Female·Aspiration pneumonia in an elderly lady
An 81-year-old woman with intellectual disability, phenylketonuria, and severe dysphagia died from aspiration pneumonia following repeated admissions for the same condition. She had been assessed as 'very high risk of as…
17y · Male·Hypoxic ischaemic encephalopathy due to hanging
A 17-year-old male who transitioned from female died by hanging on 21 April 2020, seven days after discharge from psychiatric inpatient care. He had complex medical needs including chronic back pain, spinal fusion, post-…
23y · Male·neck compression due to hanging
A 23-year-old male with drug-induced psychosis died by hanging. He had a long history of substance abuse and behavioural problems, with multiple presentations to hospital and mental health services. In March 2001, he was…
1y · Male·Pneumonia (early-onset, caused by Group B Streptococcus)
…d at one day old from early-onset pneumonia caused by Group B Streptococcus (GBS) acquired during vaginal delivery. The mother had known GBS colonisation and received intrapartum prophylactic antibiotics as per guideline…
23y · Female·complications of ruptured ectopic pregnancy with massive intra-abdominal haemorr…
A 23-year-old woman with a ruptured ectopic pregnancy at a rural hospital required urgent transfer to a tertiary centre. The initial response was classified as routine, and the first ambulance crew arrived late without a…
70y · Female·Cardiac arrest caused by a combination of gastric haemorrhage and pneumonia exac…
Mrs Kathleen Anne Conlan, 70, died from cardiac arrest caused by gastric haemorrhage and pneumonia on a background of coronary artery disease. She presented with severe epigastric pain and was appropriately admitted for …
67y · Male·ischaemic heart disease
A 67-year-old man with ischaemic heart disease and paroxysmal atrial fibrillation underwent arthrotomy for septic arthritis of the knee. He developed post-operative delirium attributed to anaesthesia, analgesics (tramado…
1y · Male·Hypoxic ischaemic encephalopathy
…definitely 20 minutes before syntocinon) may have identified foetal compromise, enabling urgent operative delivery potentially resulting in a healthy baby. Documentation errors and non-functioning labour suite clocks com…
15y · Female·Paracetamol toxicity in the setting of Anorexia Nervosa
Olivia Evans, 15, died from paracetamol toxicity in the setting of anorexia nervosa after intentionally overdosing. She had 38 inpatient admissions over two years with escalating food refusal, self-harm, and suicidal beh…
56y · Male·Pulmonary thromboemboli due to deep vein thrombosis due to immobility due to hea…
A 56-year-old concreter died from pulmonary embolism secondary to deep vein thrombosis and immobility following a severe head injury sustained when struck by a concrete pump hose that had undergone hose whip. The hose bl…
45y · Male·atherosclerotic heart disease
Lex Gregory Maher, a 45-year-old Aboriginal man imprisoned at Greenough Regional Prison, died of atherosclerotic heart disease while playing basketball. He had abnormal ECGs detected in March and May 2022 and was appropr…
22y · Male·Multiple injuries secondary to fall from a height
…und the death could not be proven preventable with certainty, she identified significant failures in care delivery versus documented plans, inadequate engagement with an acutely unwell paranoid patient, and systemic gaps…
38y · Male·Compression of the neck (hanging)
Jason Muir, a 38-year-old Aboriginal man, died by suicide 24 days after release from custody. He had complex psychosocial needs including mental health issues, substance use history, and prior suicide attempts. While rei…
31y · Male·Acute colonic pseudo-obstruction; death certificate amended to 'unascertained' -…
Cameron Yeates, a 31-year-old man with intellectual disability (IQ 64) and longstanding gastrointestinal issues, died from acute colonic pseudo-obstruction with underlying malnourishment. Key clinical lessons: (1) severe…
37y · Female·asphyxia due to hanging
A 37-year-old woman with major depression and Crohn's disease was admitted to hospital following a suicide attempt. She was discharged after less than two days following clinical improvement, against her husband's reserv…
29y · Male·Multiple injuries sustained in a train incident (intentional self-harm)
Grant Phillips, 29-year-old with schizophrenia and complex psychiatric history including multiple suicide attempts, was admitted involuntarily to Broadmeadows Inpatient Psychiatric Unit on 5 May 2007. Despite being asses…
28y · Male·Multiple drug toxicity (gamma hydroxybutyrate and methamphetamine) with cardiore…
…ge of recovery. The case highlights systemic gaps in integrated mental health and substance abuse service delivery, with the coroner observing that despite decades of planning, insufficient progress has been made in prov…
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