228 results for “airway management”
29y · Male·aspiration pneumonia complicating acute and chronic Wernicke's encephalopathy an…
Grant Austin, a 29-year-old man with intellectual disability and morbid obesity, died from aspiration pneumonia complicating Wernicke's encephalopathy. He presented with prolonged refusal to eat and drink from December 2…
42y · Male·Asphyxia due to traumatic compression of the chest and airway caused by roof col…
Todd Andrew Carver, a 42-year-old truck driver, died in a rollover of a prime mover and fish tanker on Esperance Coast Road, Tasmania on 13 July 2014. He died of asphyxia when trapped in the crushed cabin. The investigat…
31y · Male·undetermined
Erol Elmas, a 31-year-old man with schizoaffective disorder, died in custody at Thomas Embling Hospital on 30 November 2022. The cause of death remains undetermined despite thorough pathological investigation. Mr Elmas w…
81y · Male·Chronic lung disease (severe COPD) with atherosclerotic cardiovascular and valvu…
…ith severe COPD died following inappropriate interhospital transfer to a private hospital and subsequent management errors. Key clinical lessons: (1) patients with CO2 retention require explicit identification on all oxy…
2y · Male·accidental drowning
A 2-year-old boy drowned at a public pool in a remote Australian community during a childcare centre excursion. Critical clinical and organisational failures contributed: no formal risk assessment was documented for the …
42y · Female·Hypoxic brain injury due to choking on food, in a person with Cornelia de Lange …
…ealth services that contributed to incomplete risk assessment and inadequate staff training on dysphagia management.
31y · Male·Complications of methylamphetamine use in a setting of physical restraint in a m…
…ere unaware of the Bunnings Code of Conduct requiring disengagement from aggressive customers; and store management training did not equip managers to supervise or intervene in such confrontations. The coroner recommende…
70y · Female·Aspiration pneumonia, associated with Huntington's disease
… agitation and increased aspiration risk, insufficient fluid and nutritional support, poor pressure area management, and delayed medical review when her condition deteriorated. The coroner found care was inadequate despi…
51y · Male·complications of opiate toxicity; cardiac and respiratory arrest following drug …
…y communication regarding custodial orders. Systemic confusion about discharge procedures and medication management also contributed to risk.
49y · Female·Intra-abdominal haemorrhage, septic and haemorrhagic shock as a result of a lapa…
Deborah Burgen died from intra-abdominal haemorrhage complicated by septic shock following delayed emergency surgery for bowel obstruction. She attended the emergency department six times over eleven days with identical …
53y · Male·Burns to 75% of body surface area and severe lower airway inhalation injury
Barry Michael Daly, 53, died from severe burns (75% BSA) and inhalation injury sustained in a deliberately-set house fire on 20 April 2008. He had been detained at Glenside Hospital on 10 April 2008 under the Mental Heal…
36y · Female·respiratory depression after loss of consciousness caused by mixed drug toxicity…
…y 1:34am when she lay down slumping. Dr V.'s evidence indicates she would likely have survived with proper airway management and oxygenation support in hospital.
20y · Female·food-induced anaphylaxis, likely to peanut allergen
…ssionals lacked consistent anaphylaxis guidelines; and the food service industry had inadequate allergen management practices. The coroner made seven recommendations addressing health professional education, development …
32y · Male·Cardiac arrest as a result of the combined effects of severe coronary atheroscle…
Tofia Mataia, a 32-year-old male with schizophrenia, died in custody at Capricornia Correctional Centre following restraint after assaulting officers. He collapsed during a 2-minute prone restraint by five officers. The …
39y · Male·respiratory failure and cardiac arrest
Bradley Karl Coolwell, a 39-year-old Indigenous Australian with schizo-affective disorder and significant comorbidities (obesity, respiratory infection, diabetes), presented to Logan Hospital after police noted concernin…
55y · Male·Complications of alcohol use disorder
Dushyanthan Visvanathan, a 55-year-old man with alcohol use disorder and prior withdrawal seizure, died in custody at MRRC from complications of alcohol use disorder. Critical failures in clinical care included: inadequa…
24y · Female·hypoxic brain damage due to cardiac arrest due to hanging
… frequent monitoring. No individual clinician was found at fault, but systemic failures in mental health management were clearly identified.
13y · Female·Pneumonia, due to or as a consequence of Hypoxic Brain Damage, due to or as a co…
Amanda Helen Boyce, aged 13, drowned in a spa pool at a resort after her long hair became entrapped in the pump suction system. She was submerged for an estimated 10-20 minutes before being freed. Despite immediate CPR a…
[18, 21, 23, 19, 22, 19]y · ["male", "female", "male", "male", "male", "female"]·MDMA toxicity (one case mixed MDMA and cocaine toxicity)
This inquest examined six deaths from MDMA toxicity after electronic dance music festivals in NSW between December 2017 and January 2019: Hoang Nathan Tran (18), Diana Nguyen (21), Joseph Pham (23), Callum Brosnan (19), …
27y · Male·Cardiac arrest due to cardiac arrhythmia triggered by prone restraint (some of w…
Michael Peachey, a 27-year-old First Nations man, died in custody following a police-initiated restraint during an acute psychotic episode. Over preceding days, his family repeatedly sought mental health intervention. On…
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