329 results for “delivery”
43y · Male·Pneumonia
Jeffrey John Hartwig, a 43-year-old with chronic schizophrenia and opiate dependence, died from pneumonia following cardiorespiratory collapse on an acute psychiatric inpatient unit. He was on multiple psychoactive medic…
72y · Female·Intrathecal toxicity of bupivacaine and morphine
…ntending epidural administration but the line was intrathecal. These doses were excessive for intrathecal delivery. The patient collapsed within 35 minutes, with profound hypotension (56/32) and respiratory depression. S…
89y · Female·Burn wounds and the consequences thereof
… control device (TCD) when replacing her hot water system on 19 April 2022. Regulations mandate hot water delivery at bathtubs not exceed 50°C; without a TCD, her system delivered water at 70°C. The coroner found systemi…
25y · Male·drowning
Matthew Leary, 25, died by suicide at Watsons Bay on 28 November 2014 after three psychiatric admissions in one month. Key clinical lessons: mental health clinicians at Prince of Wales Hospital and St Vincent's Hospital …
25y · Female·Stab wounds to the chest and abdomen
Rebecca Lazarus, a 25-year-old woman with intellectual disability, was fatally stabbed by her partner Travis Cooke who had chronic treatment-resistant paranoid schizophrenia, was on a Community Treatment Order, and had a…
61y · Male·exposure and dehydration, preceded by alcohol withdrawal and chronic alcoholism
A 61-year-old man with chronic alcoholism was admitted to hospital for alcohol withdrawal management. He became confused and paranoid on the ward, received appropriate medication, but left hospital unobserved approximate…
drowning
This joint inquest examined eight deaths of children aged 14 months to 3 years who drowned in home swimming pools in NSW between June 2006 and January 2009. The coroner concluded all deaths were preventable. Contributing…
Male·Head injuries from motor vehicle accident
On 10 December 2001, Tristram Rich (16, learner driver) was driving a stolen Holden Commodore on the Hume Freeway when intercepted by police. Rich fled and a 20-minute pursuit ensued at speeds up to 210 km/h involving mo…
0y · Female·Hypoxic-ischaemic encephalopathy arising from thrombosis in Blalock-Taussig shun…
Holly South, an 8-month-old with complex congenital heart disease requiring a Blalock-Taussig shunt, died of hypoxic-ischaemic encephalopathy from thrombosis in her shunt after presenting to hospital with vomiting and si…
0y · Female·Complications of spinal muscular atrophy
Frankie Skye Foulkes, a four-month-old diagnosed with spinal muscular atrophy type 1, died from complications of SMA while positioned in a standard car seat during a car journey. She had recently commenced nusinersen tre…
52y · Male·hypoxic-ischaemic encephalopathy due to cardiac arrest due to unknown aetiology
James Halloran, age 52, collapsed during chiropractic treatment and suffered cardiac arrest of unknown aetiology. He remained unconscious despite resuscitation and died from hypoxic-ischaemic encephalopathy. Initially su…
19y · Male·gunshot wounds to chest and abdomen
…November 2019. This coroner's report focuses on systemic failures in policing, youth services, and health delivery in remote Aboriginal communities. Key clinical/public health lessons include: inadequate mental health an…
15y · Male·Multiple organ failure associated with hyperthermia (heat stroke)
A 15-year-old rugby league player died from heat stroke during training on an extremely hot Perth summer evening (44.4°C). The coaching staff appropriately applied NRL heat guidelines in deciding to proceed with modified…
29y · Female·Multiple stab wounds to the neck
A woman was fatally stabbed 12 times in the neck by her husband during an escalating family violence situation. She had disclosed family violence to Victoria Police on multiple occasions and to her General Practitioner. …
12y · Male·Suicide by hanging
A 12-year-old Aboriginal boy living in a remote Queensland community died by suicide by hanging following his placement in alternative care by child protection services. The boy had multiple vulnerabilities including fet…
Male·Suffocation as a result of acute petrol vapour inhalation
Three Aboriginal males died from acute petrol vapour inhalation while sniffing in remote Northern Territory communities. Napthan Presley (14 years, Willowra), Wallace Coulthard (21 years, Mutitjulu), and Trevor Brumby (3…
81y · Female·Complications of choking on a food bolus in a woman with dementia
Dorothy May Nelson, an 81-year-old woman with dementia, died from complications of choking on a food bolus at an aged care facility. She was served diced beef in casserole (approximately 4cm bolus found at autopsy, despi…
37y · Female·Hypoxic brain injury complicating cardiorespiratory arrest during manual removal…
…d primigravida with gestational diabetes was admitted for labour induction at 37 weeks. Following vaginal delivery and delayed placental separation, manual removal of placenta was performed under spinal anaesthesia. The …
35y · Female·Multiple injuries in a cyclist in a heavy vehicle collision
Arzu Karakoc, 35, died in a collision between her bicycle and a heavy truck at the Whitehall Street and Somerville Road intersection in Yarraville on 10 March 2017. Both the truck driver and cyclist had simultaneous gree…
0y · Female·Perinatal asphyxia
A 10-day-old infant died from perinatal asphyxia after being born in a home birthing pool. The mother entered the pool without a midwife present after spontaneous rupture of membranes during precipitous labour. Critical …
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