Coronial

258 results for hypoxic_brain_injury

VIChospital2015-10-22

Finding into death of Emilie Suzanne Le Coz

31y · Female·raised intracranial pressure due to ventriculoperitoneal shunt dysfunction (disc…

Emilie Le Coz, aged 31, died from raised intracranial pressure secondary to ventriculoperitoneal shunt disconnection. She presented to hospital in March 2010 with progressive headaches, cognitive changes and behaviour de…

neurologyneurosurgerydiagnosticcommunicationpropranolol
VIChospital2013-05-10

Finding into death of Joseph Thurgood Gates

0y · Male·Global cerebral hypoxic injury and perinatal asphyxia secondary to uterine ruptu…

Joseph Thurgood-Gates died at 5 days old from global cerebral hypoxic injury due to uterine rupture during labour. The death was preventable. His mother, Ms Thurgood, had two prior caesarean sections and refused hospital…

obstetricsmidwiferydiagnosticcommunication
NTcommunity2024-11-15

Inquest into the death of Kumanjayi Jurrah

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 …

public healthemergency medicineproceduralsystem
SAhospital2023-07-28

Coroner's Finding: Searle, Bodhi Leo

0y · Male·hypoxic ischaemic encephalopathy due to intrapartum asphyxia

Bodhi Leo Searle, aged 36 hours, died from hypoxic ischaemic encephalopathy due to intrapartum asphyxia. He was born to a woman in low-risk labour managed initially by independent midwife Stephanie Geyer. When labour did…

obstetricsmidwiferydiagnosticcommunication
WAhospital2020-05-26

Inquest into the Death of Nualla Christine REILLY

74y · Female·Multiple injuries sustained when struck by train

A 74-year-old woman with borderline personality disorder, depression, anxiety and type 2 diabetes died by suicide after absconding from Fiona Stanley Hospital Emergency Department. She had been on extended psychiatric ad…

psychiatryemergency medicinecommunicationsystemamitriptyline
NSWhospital2014-09-26

Inquest into the death of AA

10y · Male·Hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…

A 10-year-old boy with severe obstructive sleep apnoea and morbid obesity died from hypoxic brain injury following cardiorespiratory arrest. Despite repeated medical interventions and explicit warnings that his condition…

respiratory medicineendocrinologycommunicationsystemmethadone
VIC2016-04-29

Finding into death of Jack Glen Irvine

15y · Male·Global ischaemic brain injury post cardiac arrest secondary to anaphylaxis

Jack Glen Irvine, a 15-year-old with documented severe nut allergies and asthma, died from anaphylaxis triggered by consuming a macadamia nut cookie at a Victorian Karting Association camp. The cookie was provided despit…

emergency medicineintensive caresystemcommunicationadrenaline
VIChospital2013-02-22

Finding into death of Domenico Chiodo

33y · Male·Cardio-respiratory arrest in the setting of prone restraint of an agitated obese…

A 33-year-old man with schizophrenia and a forensic history suffered cardio-respiratory arrest during prone restraint in a busy emergency department after his mental health community treatment order was revoked. He was a…

emergency medicinepsychiatrydiagnosticmedicationolanzapine
SAhospital2018-07-19

Coroner's Finding: ROSS Chrystal Jessica

24y · Female·hypoxic brain injury secondary to hanging

Chrystal Ross, a 24-year-old woman, died by hanging in hospital in January 2015 after a catastrophic chain of communication failures and care coordination errors. She had been admitted to Mount Barker Hospital for anxiet…

psychiatrygeneral practicecommunicationdiagnosticfluvoxamine
TAScommunity2023-05-19

Coroner's Finding: Kirkwood, Jordan Thomas

19y · Male·hypoxic brain injury following asphyxia due to hanging

Jordan Kirkwood, a 19-year-old male, died by hanging on 30 April 2019 after being admitted to a newly established community-based mental health program (MHHITH) on 3 April 2019. He presented with depression, cannabis wit…

psychiatryemergency medicinediagnosticcommunicationfluoxetine
NSWhospital2014-09-26

Inquest into the death of AA

10y · Male·hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…

AA, a 10-year-old boy with morbid obesity and severe obstructive sleep apnoea, died from hypoxic brain injury after a cardiorespiratory arrest. He had been admitted to hospital in May 2008 with these diagnoses and was pr…

respiratory medicineendocrinologycommunicationsystemmethadone
WA

Inquest into the Death of Stanley John INMAN

19y · Male·complications of ligature compression of the neck

Stanley John Inman, 19-year-old Aboriginal male, died by suicide at St John of God Midland Hospital on 13 July 2020, two days after ligature compression of the neck at Acacia Prison. He was on low-level ARMS (at-risk man…

psychiatrypsychologycommunicationsystemmirtazapine
VIChome2016-03-24

Finding into death of Caroline Emily Lovell

36y · Female·Global ischaemic injury following cardiorespiratory arrest in the immediate post…

Caroline Lovell, 36, died from postpartum haemorrhage following home birth of her second child. She had significant risk factors: prior PPH with first child and uterine fibroid, but these were not properly investigated b…

midwiferyobstetricsdiagnosticcommunicationsyntocin
NSWhospital2022-12-21

Inquest into death of Andrea LESTER

49y · Female·Hypoxic brain injury related to tracheostomy complications in form of airway occ…

Andrea Lester, age 49, suffered a subarachnoid haemorrhage from a PICA aneurysm in March 2018 with delayed diagnosis. Following complex neurosurgery causing Wallenberg syndrome, she required tracheostomy for bulbar dysfu…

neurosurgeryintensive carediagnosticcommunicationtramadol
ACT1999-06-28

Inquest Into The Manner And Cause Of Death Of Mark Robert Watson

17y · Male·Cerebral ischaemia caused by hanging at Quamby Youth Detention Centre at approxi…

Mark Watson, a 17-year-old boy charged with assault, was detained at Quamby Youth Detention Centre. During his second remand in September 1996, after a failed hospital admission, he returned to the same unit where he had…

psychiatrypsychologysystemsupervision
SAmental health2025-04-17

Coroner's Finding: Furlan, Mark John & Miller, Richard John

50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…

Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…

psychiatryemergency medicinediagnosticcommunicationescitalopram
WAhospital2013-01-17

Inquest into the Death of Mckay-Hall, Julienne Maria

46y · Female·Complications following cardiorespiratory arrest in association with an air embo…

A 46-year-old woman died from air embolism during a gastroscopy to manage complications from bariatric surgery. The initial laparoscopic sleeve gastrectomy on 9 November 2007 had a staple misfire that was inadequately re…

general surgerybariatric surgerydiagnosticcommunicationmorphine
VIChome2025-07-28

Finding into death of Heather Ida Simone Calgaret

30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…

Heather Calgaret, a 30-year-old Aboriginal woman, died from hypoxic ischaemic encephalopathy after being administered a first dose of buprenorphine (Buvidal) injection without prior stabilisation on sublingual Suboxone. …

general practiceaddiction medicinemedicationdiagnosticbuprenorphine

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