325 results for “ischaemic injury”
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
…iencies: inadequate urine output monitoring (no urinary catheter despite critical illness and acute kidney injury); delayed and sub-optimal antibiotic dosing and timing; failure to place arterial line for continuous bloo…
0y · Female·brain death complicating head and neck injury
A five-month-old girl died from catastrophic brain injuries caused by violent shaking on 20 May 2019. Medical evidence established she was shaken by an adult on at least two occasions: once around 6 May 2019 (evidenced b…
0y · Female·Perinatal asphyxia
Baby M was born at 38+4 weeks gestation in poor condition at The Royal Women's Hospital on 10 November 2022 and died at 24 minutes of age from perinatal asphyxia. Autopsy findings suggested cord compression occurring 4-6…
35y · Male·subarachnoid haemorrhage with antecedent ruptured cerebral artery aneurysm
…staff at hospitals later recognised a ruptured aneurysm, but it was too late to prevent catastrophic brain injury and death. The coroner found the delay in medical assessment 'disgraceful'. Officers required training to …
Zara Schupelius: suffocation; Callum Smith: undetermined; Jake Hackett: suffocat…
Concurrent inquests into five sudden unexpected deaths in infancy (SUDI), three attributed to suffocation and two undetermined but with suffocation as a significant possibility. All deaths occurred in infants aged 2-7 mo…
86y · Female·subdural haemorrhage due to or as a consequence of a fall
Ms SME, an 86-year-old resident at a Blue Care nursing home, suffered a fatal subdural haemorrhage following a fall from bed during a sponge bath on 18 January 2016. She died on 21 January 2016. Clinical lessons include:…
41y · Male·acute, severe hydrocephalus contributed to by longstanding chronic hydrocephalus…
…ruary 2021, two days after release from Parklea Correctional Centre, ultimately resulting in hypoxic brain injury and death. Critical failures in release planning contributed to this preventable death: Benjamin was not p…
1y · Female·Dilated cardiomyopathy
An 18-month-old girl died from dilated cardiomyopathy masquerading as croup. While initially misdiagnosed as croup was reasonable, the failure to reassess when clinical improvement did not occur was critical. Key failure…
89y · Male·multi-organ failure with pneumonia due to ingestion of a corrosive liquid (quate…
An 89-year-old man with severe dementia died from multi-organ failure following ingestion of concentrated Bacban (quaternary ammonium compound) left in his bathroom at an aged care facility. The cleaning staff member ina…
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…
37y · Male·acute heart failure caused by multiple drug toxicity (methadone and alprazolam)
Richard Mark Kiel, a 37-year-old with chronic opioid addiction, died from acute heart failure caused by lethally high levels of methadone and alprazolam, likely consumed on 9 September 2005. His GP, Dr G., prescribed the…
37y · Female·Multiple injuries
Sarah Michele Kajoba, aged 37, died from multiple traumatic injuries sustained when a timber balcony collapsed at a Christmas party on 16 December 2017. The balcony had been undersized from construction in 1987, with ina…
0y · Male·Complications following forceps delivery
A 3-day-old neonate died from complications of instrumental forceps delivery, specifically subgaleal haemorrhage with associated skull fracture and intracranial bleeding. Critical clinical lessons include: (1) complex fo…
24y · Male·Multiple organ failure due to or as a consequence of severe thermal burns
Omid Masoumali, a 24-year-old Iranian refugee detained on Nauru under Australian offshore processing arrangements, suffered severe thermal burns (>50% TBSA) on 27 April 2016 after self-immolating at the Nibok settlement.…
72y · Female·Obstruction of the airways of the neck
A 72-year-old woman with moderate-severe expressive and receptive dysphasia following an acute left middle cerebral artery stroke died by hanging three months post-discharge from rehabilitation. Critical deficiencies wer…
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…
31y · Male·Hypoxic ischaemic encephalopathy following out of hospital cardiac arrest in a m…
31-year-old Darren Culleton died from hypoxic brain injury after choking on the hood of his coveralls while in police custody. He had presented to St Vincent's Hospi…
62y · Male·Cerebral ischaemic injury due to hanging
Gerard Helliar, a 62-year-old man with severe bipolar affective disorder, died from hanging in Frankston Hospital psychiatric ward on 16 November 2012 after an involuntary admission for treatment-resistant depression wit…
68y · Male·surgical complications following laparoscopic cholecystectomy for cholecystitis,…
Cyril Churchill, a 68-year-old man with multiple comorbidities, died from surgical complications after laparoscopic cholecystectomy for acute cholecystitis. Postoperatively, he developed profound hypotension. The treatin…
64y · Male·hypoxic-ischaemic encephalopathy complicating cardiac arrest due to retroperiton…
…diac arrest caused by retroperitoneal bleeding from a pelvic fracture. The bleeding occurred six days post-injury while on high-dose enoxaparin (100mg twice daily) initiated under an orthopaedic protocol. Critical failin…
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