Coronial

228 results for airway management

VICaged care2025-07-24

Finding into death of Silvie Marion Burton

89y · Female·Acute upper airway obstruction by food bolus

An 89-year-old woman with dementia died from acute upper airway obstruction by food bolus while being fed lunch at an aged care facility. CCTV footage revealed significan…

geriatric medicineemergency medicineproceduraldelaycitalopram
VIChospital2021-07-20

Finding into death of Gela Anne Vigor-Newitt

72y · Female·Pneumonia as a consequence of chronic obstructive airway disease

Ms Vigor-Newitt, a 72-year-old woman in prison, died from pneumonia complicated by chronic obstructive airway disease. She had presented with respiratory symptoms on 27 and 29 September 2020 and was appropriately hos…

respiratory medicinecardiologysalbutamol
VIChospital2021-10-25

Finding into death of MR XH

46y · Male·Hypoxic ischaemic brain injury complicating a cardiac arrest during anaesthetic …

…severe hypoxic brain injury had occurred, leading to brain death. Key lessons: maintain high suspicion for airway malposition despite initial visualization; rely on capnography waveform as the most reliable confirmation;…

anaesthesiaintensive carediagnosticproceduralfentanyl
NSW2012-05-15

Grainger ,helen finding 1767 08 2012 05 31 14 40 06 300

29y · Female·Hypoxic Encephalopathy consequent upon Cardiorespiratory Arrest arising from eit…

Helen Grainger, 29, with polycystic kidney disease and asthma, underwent pregnancy termination at Lambton Road Day Surgery in April 2007. She developed anaphylaxis post-procedure (likely cephalosporin-triggered) with car…

general practiceobstetricsproceduralsystemcephalosporin
QLDhome2019-04-17

Davis, John

50y · Male·Hypoxic-ischaemic encephalopathy secondary to choking on food bolus

… dispatcher delayed recognition of cardiac arrest. Paramedics initially failed to visualise and remove the airway obstruction due to inexperience with laryngoscopy and faulty equipment; a critical care paramedic removed …

emergency medicineparamedicinediagnosticcommunicationmidazolam
VICmental health2025-05-19

Finding into death of Anna Lee

70y · Female·Asphyxia due to airway obstruction

Anna Lee, a 70-year-old retired psychiatric nurse, died from asphyxia due to airway obstruction while an inpatient in a mental health unit. She was admitted with first-episode mania with psy…

psychiatrygeriatric medicinesystemolanzapine
VIChospital2019-03-01

Finding into death of Madeleine Therese Sobb

25y · Female·Airway obstruction complicating laryngeal dilation for the treatment of subglott…

Ms Sobb, a 25-year-old woman with spondylo-epi-metaphyseal dysplasia causing severe airway abnormalities and subglottic stenosis, died from airway obstruction following laryngeal dilation. She was …

intensive careemergency medicinecommunicationsystemadrenaline
VICcommunity2025-07-17

Finding into death of John Michael Jurdeczka

62y · Male·Hypoxic ischaemic encephalopathy complicating cardiac arrest in setting of acute…

…, and dysphagia, died from hypoxic ischaemic encephalopathy following cardiac arrest caused by acute upper airway obstruction from a food bolus. During a community outing, despite having a detailed Mealtime Management Pl…

speech pathologygeneral practicecommunicationsystemmorphine
QLD2007-02-21

Russell, Andrew John and Harogh, Bianca Joan

19y · Unknown·Russell: unconsciousness superimposed on airway obstruction due to severe seatbe…

…l of his vehicle while travelling at excessive speed on Bridge Street, Wilsonton. Andrew Russell died from airway obstruction due to severe seatbelt compression of the neck combined with unconsciousness and anoxia. Bianc…

VICcommunity2024-07-29

Finding into death of Andrew David Berry

41y · Male·sympathomimetic syndrome

Andrew Berry, a 41-year-old man with a long history of methamphetamine use and criminal offending, died of sympathomimetic syndrome following arrest by police on 14 January 2020. He was arrested after attempting to break…

emergency medicineforensic medicinesystemdelaymethamphetamine
VIChospital2012-07-16

Finding into death of Ruben Chand

42y · Male·Hypoxic encephalopathy in the setting of recent acute myocardial infarction with…

…ation decision, he deteriorated and required urgent re-intubation. The procedure was complicated by a poor airway view (Grade 2B-3), inadequate pre-oxygenation, failure to use a bougie despite difficulty, lack of capnogr…

intensive careanaesthesiaproceduralcommunicationpropofol
VICcommunity2022-02-18

Finding into death of Roger David Batchelor

57y · Male·Hypoxic ischaemic encephalopathy secondary to prolonged downtime due to upper ai…

…ectual disability and a documented history of choking died from hypoxic ischaemic encephalopathy following airway obstruction by food at a day activities program. Despite having a choking management plan in place since 2…

general practicespeech pathologycommunicationsystempantoprazole
VIChospital2016-05-26

Finding into death of Delta Diawo Poke

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

…e the patient was awake. He administered propofol, fentanyl, and midazolam without baseline vital signs or airway protection, creating significant risk of hypoxaemia. The surgeon, Dr S., was not alerted to these difficul…

anaesthesiaobstetricsdiagnosticmedicationpropofol
VIChospital2024-08-30

Finding into death of Betty Eileen Cliffe

85y · Female·Asphyxia due to upper airways obstruction by mucoid plugging of the upper airway…

…ffe, 85-year-old with intellectual disability and oropharyngeal dysphagia, died from asphyxia due to upper airway mucoid plugging on a background of cardiomegaly and heart failure. She was admitted to hospital on 9 April…

respiratory medicinespeech pathology
ACThospital2020-02-20

Inquest into death of JULIE ANN HERMANS

54y · Female·Multiple organ failure, due to pneumonia in a patient with Guillain-Barré syndro…

…ith appropriate multidisciplinary involvement. Extensive discussions occurred regarding feeding safety and airway management, with consensus that intubation was not warranted based on her ability to maintain her airway a…

intensive caregeneral medicine
TAShome2020-05-15

Coroner's Finding: Hunter, Feryne Gaylene

75y · Female·Airway obstruction due to aspiration occluding a permanent tracheostomy

Feryne Gaylene Hunter, aged 75, died from airway obstruction due to aspiration into her permanent tracheostomy. She had a history of subglottic stenosis, a…

paramedicinegeneral practicecommunication
VIC2025-09-10

Finding into death of Tracie Lyndal Markwick

54y · Female·choking on a food bolus in a woman with an intellectual disability and other med…

…lity and dysphagia, died from choking on food at her day placement centre. She had a documented mealtime management plan indicating mild-to-moderate choking risk, requiring small food pieces, close monitoring, and 30-min…

speech pathologyemergency medicineamisulpride
VIChospital2024-02-19

Finding into death of Kathryne Frances Callaghan

51y · Female·Aspiration pneumonia in a woman with cerebral palsy and epilepsy

…agia and reduced consciousness, particularly post-infection, and the importance of nutritional and fluid management strategies in such vulnerable populations.

general practicerespiratory medicineparacetamol
SAhospital2021-06-30

Coroner's Finding: MAZMANIDIS Kiriakos Jack

83y · Male·respiratory failure due to chronic obstructive lung disease

…ipsychotics under a Mental Health Act order. Despite treatment, his condition deteriorated due to advanced airway disease unresponsive to non-invasive ventilation. The coroner found care was appropriate and no preventabi…

respiratory medicineintensive carehaloperidol
VIChome2024-12-12

Finding into death of L G

16y · Male·Complications of acute alcohol intoxication

…door couch. Clinical lessons: acute alcohol intoxication in young people causes respiratory depression and airway compromise risk; loud snoring during unconsciousness indicates severe CNS depression requiring immediate m…

emergency medicinetoxicologydelaysystemalcohol

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