Coronial

36 results for blood sampling

VIChospital2022-08-19

Finding into death of Ruth Ann McKenna

62y · Female·Hypovolaemic and cardiogenic shock (hysterectomy) in the context of cardiomegaly…

…cardiogenic shock during elective total laparoscopic hysterectomy for an endometrial polyp. Intraoperative blood loss was 2000-2500mls (far exceeding typical 150-200mls). Critical gaps included: surgery commenced withou…

gynaecologyanaesthesiadiagnosticsystemmetaraminol
VIChospital2018-10-11

Finding into death of Sununtha Suttha

57y · Female·Haemopericardium complicating ascending thoracic aortic dissection

A 57-year-old woman presenting to the ED with sudden-onset sharp mid-back pain, syncope, shortness of breath, and lower limb neurological symptoms was diagnosed with musculoskeletal back pain and discharged after normal …

emergency medicinecardiothoracic surgerydiagnosticcommunicationparacetamol
NSWhospitalPodcast2021-05-07

Inquest into the death of Brent Justin CROUGH

24y · Male·Complications of Brown Snake Bite

Brent Crough, a 24-year-old man, died from complications of brown snake bite in hospital. He was bitten on his right finger while separating the snake from his dog and was transported to Tamworth Base Hospital. Despite a…

emergency medicinetoxicologysystemdelaybrown snake antivenom
VIChospital2015-11-30

Finding into death of Maria Dolores Coliero

69y · Female·Inadvertent intravenous administration of oral ciprofloxacin in the setting of a…

A 69-year-old woman with stroke, diabetes, atrial fibrillation and osteomyelitis died from inadvertent intravenous administration of crushed oral ciprofloxacin. The antibiotic was prescribed for the nasogastric tube but …

intensive careinfectious diseasesmedicationproceduralciprofloxacin
NSWhospital2026-03-19

Inquest into the death of Eve Brown

42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…

Eve Brown, a 42-year-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ri…

emergency medicinegeneral practicediagnosticcommunicationceftriaxone
VIChospital2022-07-28

Finding into death of H C

6y · Male·Global cerebral ischaemia secondary to perinatal asphyxia

…cumented decreased fetal movements in the week prior; (2) the abnormal CTG at 9:30pm required either fetal blood sampling or expedited delivery, but management was delayed approximately 1.5 hours; (3) communication fail…

obstetricsneonatologydiagnosticcommunication
SAhospital2008-06-06

Coroner's Finding: AUSTIN Grant Aaron

29y · Male·aspiration pneumonia complicating acute and chronic Wernicke's encephalopathy an…

Grant Austin, a 29-year-old man with intellectual disability and morbid obesity, died from aspiration pneumonia complicating Wernicke's encephalopathy. He presented with prolonged refusal to eat and drink from December 2…

general medicinepsychiatrycommunicationdiagnostictrimethoprim
QLDhospital2005-08-24

Sabadina, Kathryn Marnie

28y · Female·Anaphylactic reaction to anaesthetic drug (suxamethonium), with underlying coron…

A 28-year-old woman died during routine dental extraction under general anaesthesia at a regional hospital. Despite competent initial airway management, she developed severe respiratory distress immediately after inducti…

anaesthesiadentistrydiagnosticproceduralpropofol
NSWhospital2018-11-09

Inquest into the death of Alexander Costello

37y · Male·Haemopericardium secondary to aortic dissection

Alexander Costello, 37, presented to Gunnedah Hospital ED with acute onset severe chest pain, back pain, diaphoresis and nausea. Dr G., the sole ED physician, conducted initial assessment including ECG and troponin testi…

emergency medicinegeneral practicediagnosticcommunicationmorphine
VIChospital2014-07-28

Finding into death of Glen David Kingsun

42y · Male·Cardiac arrhythmia secondary to electrolyte imbalance (hyperkalaemia) and verapa…

Glen Kingsun, 42, died from cardiac arrhythmia secondary to electrolyte imbalance and verapamil toxicity. He had complex medical needs requiring multiple specialist and GP care. Critical failures occurred: (1) Medication…

general practiceemergency medicinemedicationcommunicationverapamil
VICaged care2020-10-22

Finding into death of Phillip Harry Parker

61y · Male·Pneumonia

A 61-year-old man with significant medical complexity including acquired brain injury, bronchiectasis, pulmonary fibrosis, and dysphagia died from pneumonia 26 days after receiving another resident's slow-release opioid …

geriatric medicineemergency medicinemedicationsystemtapentadol sr
QLDhospital2024-06-21

Non-inquest findings into the death of Mr K

81y · Male·Chronic lung disease (severe COPD) with atherosclerotic cardiovascular and valvu…

An 81-year-old man with severe COPD died following inappropriate interhospital transfer to a private hospital and subsequent management errors. Key clinical lessons: (1) patients with CO2 retention require explicit ident…

respiratory medicineemergency medicinemedicationcommunicationdiazepam
WAhospital2023-02-22

Inquest into the Death of Aishwarya Aswath CHAVITTUPARA

7y · Female·multiorgan failure due to fulminant sepsis (Streptococcus pyogenes)

7-year-old Aishwarya Aswath Chavittupara died from multiorgan failure due to fulminant sepsis (Streptococcus pyogenes) after approximately 90 minutes in Perth Children's Hospital emergency department. She presented with …

emergency medicinepaediatricsdiagnosticcommunication
NThospital2009-04-09

Inquest into the death of Georgia Rae Tilmouth

0y · Female·Organ failure caused by not receiving enough oxygen during labour (intrapartum h…

Georgia Rae Tilmouth was born at 35 weeks gestation after premature labour and died 13 hours later from perinatal asphyxia due to hypoxia during labour. The coroner found multiple deficiencies in obstetric care contribut…

obstetricsmidwiferydiagnosticcommunicationoxytocin
QLDhospital2017-06-28

Tonkin, Nixon Martin

0y · Male·Head injuries (birth trauma) secondary to obstructed labour and fetal macrosomia…

Nixon Martin Tonkin died from head injuries sustained during caesarean delivery for obstructed labour at 38 weeks gestation. The infant's head became deeply impacted in the maternal pelvis after prolonged second-stage la…

obstetricsanaesthesiadiagnosticcommunicationoxytocin
WAhospital2006-05-31

Inquest into the Death of nilon

67y · Female·Pneumonia (streptococcus pneumoniae) in a woman receiving treatment for carcinom…

Peggy Anne Nilon, 67, died from pneumonia (streptococcus pneumoniae) at St John of God Hospital Bunbury on 25 February 2003. Her small cell lung cancer had achieved remission following chemotherapy and radiotherapy. A cr…

oncologygeneral practicediagnosticcommunicationcisplatin

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