Coronial

265 results for intubation and ventilation

SAhospital2003-12-19

Coroner's Finding: HAWKE Anne Elizabeth

33y · Female·Raised intracranial pressure secondary to thrombosis of the superior sagittal, t…

…mbosis (CVT) was not pursued despite radiologists recommending MRI. Poor communication between radiologists and neurosurgeons meant the on-call neurosurgeon was given an incomplete clinical picture, leading to conservat…

neurosurgeryradiologydiagnosticcommunicationoral contraceptive pill
VIChome2026-05-29

Finding into death of Baby R

0y · Male·Perinatal hypoxia

…obstetric risk factors: previous emergency caesarean section, macrosomic first baby, postpartum hemorrhage, and obstructed labor. Private midwife Ms Murphy assured the mother homebirth was suitable without arranging the…

obstetricsmidwiferydiagnosticcommunication
QLDhospital2009-12-16

Davidson, Yvonne Alice

75y · Female·Septicaemia as a result of lobar pneumonia; congestive heart failure also presen…

… The procedure deviated significantly from the established ICU protocol: it was performed by one consultant and a junior doctor instead of two consultants, without bronchoscope visualization as required, with non-functi…

intensive careanaesthesiaproceduralcommunication
NSWhome2021-03-31

Inquest into the death of John Glen LAURENSON

47y · Male·sequelae of ruptured brain aneurysm

John Laurenson, a 47-year-old remand prisoner, died from rupture of a brain aneurysm on 20 June 2017, four days after collapsing in his prison c…

neurosurgerygeneral practicediagnosticcommunication
QLDhospital2013-04-16

Hornby, Geoffrey John

58y · Male·Respiratory failure due to or as a consequence of Chronic Obstructive Pulmonary …

Geoffrey Hornby, a 58-year-old prisoner with significant COPD, ischemic heart disease, and multiple comorbidities, died from respiratory failure secondary to COPD. He was admitted to hospital with C…

respiratory medicineemergency medicinecommunicationdelaysalbutamol
QLDhospital2013-09-12

Bligh, William John - Non-inquest findings

9y · Male·Disseminated melioidosis

William Bligh, a 9-year-old boy from Palm Island, died from disseminated melioidosis on 24 February 2013. He presented with fever and cough from 2 February,…

paediatricsinfectious diseasessystemdelayibuprofen
NSW2016-11-04

Inquest into the death of Phillip Hughes

25y · Male·traumatic basal subarachnoid haemorrhage due to vertebral artery dissection

…l patient information (vital signs, level of consciousness), resulting in suboptimal triage classification, and essential medical equipment was not immediately accessible on-field. While the umpires appropriately enforc…

emergency medicineneurosurgerycommunicationsystem
QLD2019-11-21

Gavenor, Ashley Glenfield

48y · Male·Coronary atherosclerosis and minor trauma

…shley Glenfield Gavenor, a 48-year-old Indigenous man with coronary artery disease, hypertension, diabetes, and bipolar affective disorder, died in Townsville Correctional Centre following a brief altercation with anoth…

cardiologypsychiatryaspirin
VIChome2022-10-04

Finding into death of Baby R

3y · Unknown·Unascertained - natural causes; evidence of aspiration pneumonia, hypoxic-ischae…

…dvice against unassisted home birth, the parents elected a free birth attended only by an unregulated doula and backup doula with minimal midwifery experience. Baby R appeared well initially but developed feeding diffic…

obstetricsmidwiferysystemcommunication
SAhospital2007-06-29

Coroner's Finding: COCKBURN Michael Philip

40y · Male·respiratory failure due to Adult Respiratory Distress Syndrome (ARDS)

Michael Cockburn, a 40-year-old man with treatment-resistant schizophrenia and documented severe adverse reactions to antipsychotic medications, was admitted to Royal Adelaide Hospital f…

psychiatryemergency medicinemedicationcommunicationhaloperidol
QLDhospital2007-04-05

Smith, Arthur Lawrence

75y · Male·Acute cardiac failure due to mitral valve disease (surgically treated)

Arthur Lawrence Smith, 75, underwent successful mitral valve repair and coronary artery bypass grafts at TPCH on 2 August 2004 and was discharged 5 days later. On 19 August, his w…

cardiothoracic surgeryemergency medicinecommunicationdiagnosticadrenaline
SAhospital2006-09-25

Coroner's Finding: McLEOD Peter Malcholm

28y · Male·Acute Dopamine Imbalance Syndrome

A 28-year-old man with first-episode psychosis presented with command auditory hallucinations after a motor vehicle accident. An EEG ordered to exclude organic causes showed ver…

psychiatryneurologycommunicationdiagnosticrisperidone
NSWhospital2016-12-22

Inquest into the death of Shona Hookey

29y · Female·peritonitis caused by ischaemia of the bowel due to gastrointestinal torsion (tw…

Shona Hookey, a 29-year-old Aboriginal woman with severe intellectual disability and aphasia, died of peritonitis secondary to bowel torsion. Critical failures occurred at multiple levels: car…

emergency medicineparamedicinediagnosticcommunicationparacetamol
WAhospital2020-09-04

Inquest into the Death of Malakai Matiu Ward PARAONE

0y · Male·Complications in association with fulminant sepsis in an infant (Streptococcus p…

Malakai Paraone, a seven-month-old infant, died from fulminant Streptococcus pyogenes sepsis and septic shock. Over three days, he was seen at three hospitals and a general practice clinic but sepsis was …

emergency medicineintensive carediagnosticcommunicationparacetamol
VIChospital2025-10-28

Finding into death of Christopher Gerard McIntosh

54y · Male·Respiratory failure secondary to prolonged ventilation for management of sepsis …

Christopher McIntosh, a 54-year-old man with Type II diabetes and chronic foot ulcers, died from respiratory failure secondary to sepsis arising from an infected foot ulcer …

infectious diseasesvascular surgerydiagnosticsystemantibiotics
VIChospitalPodcast2026-02-20

Finding into death of James Harilaos Tsindos

17y · Male·Hypoxic Ischaemic Encephalopathy Complicating Anaphylaxis

James Tsindos, a 17-year-old with known nut allergy and mild asthma, experienced anaphylaxis after inadvertently ingesting cashews in a vegan restaurant meal on 27…

emergency medicineallergy and immunologydiagnosticcommunicationadrenaline (epinephrine) intramuscular
NSW2019-11-08

Inquest into the death of six patrons of NSW music festivals

Unknown·MDMA toxicity (3,4-methylenedioxymethylamphetamine toxicity) in each case

Six young people died at NSW music festivals between December 2017 and January 2019 after consuming MDMA (ecstasy) at toxic levels. Nathan Tran (18), Diana Nguyen (21), Joseph Ph…

emergency medicinetoxicologycommunicationsystemMDMA
WAhospital

Inquest into the death of Amanda Dana TAUAI

21y · Female·Multiple organ failure due to undefined sepsis (toxic shock syndrome)

Amanda Dana Tauai, 21 years old, died from septic shock with multi-organ failure in March 2012 after presenting w…

general practiceemergency medicinediagnosticcommunicationmetoclopramide
SAhospital2019-05-31

Coroner's Finding: CHAPLIN Gray Clyde

81y · Male·multi-organ failure complicating multiple right-sided rib fractures due to a fal…

…ting general practitioner failed to appreciate the seriousness of this injury pattern in an elderly patient and did not seek specialist advice or arrange transfer to a tertiary centre. Multiple clinical deterioration ma…

general practiceemergency medicinediagnosticdelaymorphine sulphate
QLDcommunity2020-09-07

C - Non-inquest findings

6y · Male·Sepsis due to melioidosis

…iple presentations to a remote hospital over five days (5–10 January 2017) with fever, vomiting, diarrhoea, and headache. Initial diagnosis of viral gastroenteritis was reasonable given the rarity of melioidosis in chil…

paediatricsinfectious diseasesdiagnosticcommunicationparacetamol

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