329 results for “delivery”
3y · Male·respiratory failure, with spinal muscular atrophy an antecedent cause
Tory Ganderton, a 3-year-old boy with spinal muscular atrophy (SMA) Type 1, died of respiratory failure during inter-hospital transfer. Admitted to Shoalhaven Hospital on 7 September 2014 with pneumonia and severe malnut…
76y · Male·morphine toxicity and carcinomatosis
John Walter Hedges, a 76-year-old man with terminal metastatic cancer, died at Greenslopes Private Hospital following a morphine overdose administered by agency nurse Cornelia Empen. Hedges had two pain management routes…
6y · Male·Global cerebral ischaemia secondary to perinatal asphyxia
…ments in the week 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 witho…
52y · Male·ischaemic heart disease
Hassan Bechara, a 52-year-old prisoner, died from ischaemic heart disease in July 2017. He had complex cardiac history including dilated cardiomyopathy, triple-vessel coronary disease, and previous cardiac procedures. Cl…
Male·Kennard: Multiple injuries; Sporn: Effects of fire; McDonald: Effects of fire
Three people died in a catastrophic collision and fire in the Burnley Tunnel on 23 March 2007, caused by a truck driver (Kalwig) operating his vehicle with inadequate attention. The driver was convicted of dangerous driv…
Female·Hanging
This finding concerns the deaths of TC, a young mother, and SN, her 17-month-old daughter, who died by hanging on 21 September 2015 in Campsie, NSW. SN had significant life-limiting medical conditions including bilateral…
52y · Male·Hypoxic ischaemic encephalopathy and multi-organ failure due to coronary artery …
…ate resuscitation equipment on the dive charter vessel—no AED or bag-valve-mask available for 100% oxygen delivery; (4) John ran out of air at depth and could not maintain buoyancy. Earlier medical screening, formal dive…
86y · Female·Sepsis complicating sacral decubitus ulceration in the setting of recent surgica…
Mrs Di Quinzio, an 86-year-old woman with multiple comorbidities, was discharged from hospital to a supported residential service (SRS) after hip fracture surgery. She required two-person assistance for mobility and was …
Unknown·Choking; Mr Gesios: large bolus of bread and scrambled eggs causing complete air…
Two aged care residents died from choking on bread despite being prescribed minced and moist diets that prohibited regular bread. Mr Gesios was fed bread dipped in Milo by an inexperienced AIN without adequate supervisio…
32y · Female·Alcoholic ketoacidosis
Tamara Burt, 32, died of alcoholic ketoacidosis after isolating in her room and drinking excessively. She had bipolar affective disorder, alcohol dependence disorder, and borderline personality disorder traits. Despite o…
16y · Female·hanging
A 16-year-old Aboriginal girl died by hanging after an episode of inhalant ('chrome') use and relationship breakdown. She had chronic substance abuse, complex psychosocial needs, learning difficulties, and disengagement …
19y · Male·heroin toxicity
Marshall Carter, 19, died in custody from heroin toxicity at Yatala Labour Prison. He had a long history of drug abuse starting from age 14 and was an intravenous heroin user. Critical failures included: inadequate trans…
19y · Male·unexpected arrhythmogenic event leading to a fall from height, blunt force head …
PTE Liam Wolf, a 19-year-old Australian Army recruit, died after collapsing on an obstacle course at Kapooka during the final training exercise. He experienced a sudden unexpected cardiac arrhythmia while climbing a ladd…
33y · Female·neck compression and hanging
Natalie was a 33-year-old transgender woman with a long history of mental health conditions including severe social anxiety, agoraphobia, borderline personality disorder and PTSD, with suicidal ideation since age 17 and …
45y · Male·Abdominal injuries from being struck by reversing front-end loader
Sean Morgan-Smith, a 45-year-old Australia Post delivery worker, was struck by a reversing front-end loader while delivering mail on a residential footpath in Hun…
31y · Male·Gunshot wounds to the neck and chest
Liam Scorsese, 31, died from gunshot wounds inflicted by police during a confrontation at his estranged partner's parents' home in Queensland. He had a history of violence, substance abuse (methamphetamine, cocaine), and…
0y · Male·severe hypoxic ischaemic encephalopathy due to apparent perinatal asphyxia
…a planned home birth and died from hypoxic ischaemic encephalopathy. An obstetrician recommended hospital delivery based on the mother's previous unexplained neonatal emergency. However, Community Midwifery Program midwi…
14y · Female·Acute cerebral hypoxia arising out of suffocation due to inhalation of toxic vap…
Haley Diamond, 14, died from acute cerebral hypoxia following inhalation of volatile substances (deodorant spray) in Kununurra, WA. She suffered acute brain damage and bronchopneumonia. Clinical lessons: volatile substan…
15y · Male·Gunshot wound to the chest
Tyler Cassidy, a 15-year-old boy, was fatally shot by Victoria Police on 11 December 2008 during a mental health crisis. He had stolen two large kitchen knives from Kmart and made threatening statements, explicitly deman…
44y · Male·Multiple blunt force injuries from fall from height
…s misadventure; no individual clinician faced significant criticism, but systemic failures in BPD service delivery were identified.
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