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VIChospital2017

Finding into death of Nghi Trieu Gla Pham

4y · Male·Complications of T-cell lymphoma

Nghi Pham was a 4-year-old admitted to Sunshine Hospital with facial swelling, stridor, and upper respiratory symptoms. He was examined by emergency and ENT teams, diagnosed with adenoiditis and sinusitis, and discharged…

emergency medicineENT surgerycefalexin
NSWhome2016-11-24

Inquest into the death of Dr Beta Vandeville

46y · Female·acute mixed drug toxicity due to accidental self-administered drug overdose

Dr V., an obstetrician-gynaecologist trainee, died from acute mixed drug toxicity on 18 January 2013 following self-administration of multiple anaesthetic drugs (propofol, midazolam, fentanyl, alfentanil) via intravenous…

anaesthesiaobstetricssystempropofol
VIChospital2016-11-10

Finding into death of Beverley Joy Leggett

79y · Female·Pulmonary thromboembolism in the setting of right elective total hip replacement

A 79-year-old woman died from pulmonary embolism eight days after undergoing elective right total hip replacement. She received multimodal VTE prophylaxis including aspirin, early mobilisation, mechanical foot compressio…

orthopaedic surgeryanaesthesiasystemaspirin
NSWhospital2016-11-04

Inquest into the death of Hellen Marsh

50y · Female·Irreversible hypoxic brain injury sustained during surgery for meningioma resect…

Hellen Marsh, a 50-year-old woman with Fragile X Syndrome and a brain meningioma, died from irreversible hypoxic brain injury sustained during tumour resection surgery. Significant intraoperative blood loss (4,500ml esti…

neurosurgeryanaesthesiacommunicationmonitoring
SAhospital2016-09-29

Coroner's Finding: MCSHANE Robert Ian

66y · Male·Multi-system failure and ischaemic gut after left nephrectomy complicated by mas…

A 66-year-old man died from multi-system failure and ischaemic bowel following laparoscopic left nephrectomy complicated by massive haemorrhage and vascular injury. During surgery for renal carcinoma, the surgeon attempt…

urologyvascular surgeryproceduralsurgical judgment
QLDhospital2016-08-19

Plumb, Mark Anthony

76y · Male·Multiple organ failure due to sepsis with peritonitis and pancreatitis, secondar…

A 76-year-old man died from multiple organ failure following an ERCP procedure for gallstone removal. The procedure itself was appropriate and uneventful. Post-operatively, he developed severe abdominal pain and a CT sca…

surgeryanaesthesiadiagnosticcommunicationmorphine
TASmental health2016-08-16

Coroner's Finding: Pasinski, Alexander

59y · Male·asphyxia due to choking on food

Alexander Pasinski, age 59, died from asphyxia due to choking while an involuntary psychiatric patient in Launceston General Hospital's Northside unit. He had major depression and paranoid schizophrenia with complex psyc…

psychiatryintensive caresystemcommunicationamitriptyline
SAhospital2016-08-03

Coroner's Finding: LAMBROPOULOS Andrea

34y · Male·hypoxic-ischaemic encephalopathy following laparoscopic bariatric surgery with i…

Andrea Lambropoulos, a 34-year-old man with morbid obesity, sleep apnoea, and ischaemic heart disease, died following sleeve gastrectomy. He was admitted to HDU rather than ICU post-operatively. In HDU, he experienced re…

bariatric surgeryanaesthesiacommunicationdelaymorphine
VIChospital2016-06-24

Finding into death of Graeme John Jennings

65y · Male·staphylococcal sepsis (secondary to Staphylococcus aureus infection seeding rect…

A 65-year-old man presented with quad bike accident injuries and had markedly elevated inflammatory markers (CRP 329–556, WCC 12.3–18) during his first hospital admission. These were suggestive of developing infection, p…

general surgeryemergency medicinediagnosticcommunicationindocid
SAmental health2016-06-09

Coroner's Finding: FALLON Peter John William

40y · Male·Unascertained; likely cardiac arrhythmia secondary to cardiomegaly and morbid ob…

Peter John William Fallon, aged 40, died in the psychiatric intensive care unit at Queen Elizabeth Hospital on 2 February 2013 of unascertained cause. He had bipolar affective disorder, was on antipsychotic therapy, and …

psychiatryintensive carecommunicationsystemrisperdal consta
QLDhospital2016-06-03

James, Kesler Lee

5y · Male·Acute bronchopneumonia and diffuse alveolar damage due to acute rheumatic cardit…

A 5-year-old boy with rheumatic heart disease and acute mitral valve regurgitation presented to Mt Isa Hospital with acute heart failure. Although initially recognised as deteriorating by the paediatrician on-call, the s…

paediatricsintensive carediagnosticcommunicationfurosemide
VIChospital2016-05-26

Finding into death of Delta Diawo Poke

42y · Female·Global cerebral ischaemia in a setting of anaesthesia

A 42-year-old woman died from global cerebral ischaemia following cardiac arrest during anaesthesia for a late-term termination of pregnancy. The anaesthetist, Dr McAllister, failed to obtain or ensure a functioning puls…

anaesthesiaobstetricsdiagnosticmedicationpropofol
SAhospital2016-05-25

Coroner's Finding: PALTRIDGE Mellanie Joanne

25y · Female·ruptured splenic artery aneurysm with haemorrhage and internal blood loss

A 25-year-old pregnant woman (23 weeks) presented to hospital with sudden left upper quadrant abdominal pain and loss of consciousness. Clinical assessment identified renal colic and gallstones as likely diagnoses. She r…

obstetricsemergency medicinediagnosticdelayparacetamol
VIChospital2016-05-19

Finding into death of Josip Dobrovoljski

62y · Male·Global cerebral ischaemia secondary to intra-operative hypotension following the…

A 62-year-old man died from global cerebral ischaemia following intra-operative hypotension after protamine administration during a cardiac ablation procedure. He had suffered a severe hypotensive reaction to protamine 8…

anaesthesiacardiologydocumentationcommunicationprotamine
VIChospital2016-04-19

Finding into death of Noah Cheron-Duncan

0y · Male·Perinatal asphyxia

Noah Cheron-Duncan, a full-term neonate born at Sandringham Hospital on 19 November 2014, died from perinatal asphyxia. Labour was uncomplicated and FHR monitoring appeared reassuring, but no foetal heart rate was detect…

obstetricsmidwiferycommunicationdelaynitrous oxide
VIChospital2016-04-14

Finding into death of Kelly Maree Richards

29y · Female·Exsanguination post tubal ligation procedure

A 29-year-old woman died from exsanguination following an iatrogenic injury during elective laparoscopic tubal ligation at a regional hospital. A vascular injury to the right external iliac artery occurred during the pro…

general surgerygynaecologyproceduralcommunicationpacked red blood cells
VIChospital2016-03-15

Finding into death of Reginald John Brooks

99y · Male·Pneumonia

A 99-year-old man with cognitive decline sustained a hip fracture from a fall and subsequently underwent surgery with informed consent. He suffered cardiopulmonary arrest post-operatively and was resuscitated despite the…

general medicineorthopaedic surgerycommunicationsystem
NSWhospital2016-03-11

Inquest into the death of Elsie COGHILL

0y · Female·Hypoxic ischaemic encephalopathy caused by multiple factors including lung abnor…

Elsie Coghill, a newborn, died from hypoxic ischaemic encephalopathy due to multiple factors including an underlying lung abnormality from antenatal distress, an undetected apnoeic episode during transfer, and undiagnose…

obstetricsneonatologycommunicationsystemoxytocin
QLDhospital2016-02-22

Robertson, Elsie - Non-inquest findings

0y · Female·Hypoxic ischaemic encephalopathy due to intra-partum event and E. coli sepsis, s…

Elsie Robertson was a preterm neonate born at 30 weeks gestation from a monochoroidal diamniotic twin pregnancy complicated by Twin-to-Twin Transfusion Syndrome (TTTS) treated with laser photocoagulation at 23 weeks. She…

obstetricsneonatologycommunicationsystemmagnesium sulphate
WAhome2016-02-10

Inquest into the Death of Daniel James HALL

26y · Male·Multiple drug toxicity and bronchopneumonia

Daniel James Hall, aged 26, died on 31 July 2010 from multiple drug toxicity and bronchopneumonia after consuming approximately 10-12 OxyContin tablets over 24 hours, vastly exceeding the prescribed dose of one tablet ev…

anaesthesiaENT surgerycommunicationsystemoxycodone
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