Coronial

37 results for central catheter insertion

VIChospital2017-11-09

Finding into death of Emma Kate McGrath

19y · Female·Meningococcal septicaemia

Emma McGrath, a 19-year-old nursing student, died from meningococcal septicaemia caused by the W strain after presenting to the ED with a 12-hour history of vomiting, diarrhoea, abdominal pain and fever. The atypical pre…

emergency medicineintensive careparacetamol
WAhospital2013-11-12

Inquest into the Death of Ford, Valma May Ruth

77y · Female·Complications following a recent fracture and surgical repair of the right hip i…

… high UTI risk in elderly females; cloudy urine postoperatively suggested possible E. coli infection from catheter. (2) Single perioperative antibiotic dose (Keflin) was inadequate; infection risk appeared unrecognized. …

orthopaedic surgeryemergency medicinediagnosticsystemwarfarin
VIChospital2012-01-31

Finding into death of Judith Elizabeth Heath

68y · Female·Massive blood loss due to disconnection of haemodialysis machine

…ring routine haemodialysis for end-stage renal failure. The Luer-Lok connection between her arteriovenous catheter and the haemodialysis machine became disconnected at approximately 2:20pm. Critically, neither the machin…

nephrologyproceduralsystemheparin
SAhospital2000-05-31

Coroner's Finding: DELLATORRE Natale

54y · Male·respiratory failure and acute renal failure due to rhabdomyolysis following trau…

A 54-year-old man with chronic schizophrenia and intellectual disability died from respiratory failure and acute renal failure secondary to rhabdomyolysis following a crush injury to his left thigh sustained while attemp…

emergency medicinepsychiatrydiagnosticadrenaline
VIChospital2018-10-18

Finding into death of Maxwell Norman Campbell

68y · Male·pulmonary thromboembolism in the setting of recent surgery

A 68-year-old man died from pulmonary thromboembolism following revisional gastric bypass surgery. He developed multiple post-operative complications including fever, elevated inflammatory markers, and a possible bowel p…

bariatric surgerygeneral surgeryheparin
QLDhospital2012-12-06

McNaught, Judith

69y · Female·Septic shock due to biliary peritonitis as a consequence of laparoscopic cholecy…

A 69-year-old woman died of septic shock following bile leak complications after laparoscopic cholecystectomy. Critical failures included: (1) inappropriate transfer to low-dependency unit on post-op day 1 despite consul…

surgeryanaesthesiadiagnosticmedicationmorphine
WAhospital- 27 May 2014

Inquest into the Death of Julissa Teresa GILBERT

57y · Female·Intra-abdominal Haemorrhage following Appendectomy, with contributing factor of …

A 57-year-old woman with COAD, hypertension, and unrecognized severe coronary atherosclerosis presented with appendicitis. Surgery was performed by an unsupervised surgeon operating on friable tissues with limited visibi…

anaesthesiasurgerydiagnosticcommunicationaramine
NThospital2015-07-10

Inquest into the death of Clare Harrison

29y · Female·multi-lobe community acquired pneumonia and respiratory failure

Clare Louise Harrison, a 29-year-old woman with long-standing anorexia nervosa diagnosed at age 17, died from community-acquired pneumonia and respiratory failure after a final 21-day admission to Alice Springs Hospital.…

psychiatrygeneral medicineantibiotics
NSWhome2010-08-26

Coroner's Finding: Kate Therese Bugmy

26y · Female·Streptococcal Sepsis resulting from Skin Ulceration and complications of Cerebra…

Kate Therese Bugmy, a 26-year-old woman with cerebral palsy, epilepsy, and intellectual disability, died on 28 June 2007 of Streptococcal sepsis from infected pressure ulcers. She was cared for at home by her mother Daph…

general medicineemergency medicinesystemcommunication
NSW2018-10-26

Inquest into the death of Mahmoud Houri

27y · Male·multiple organ failure due to the consequences of multiple gunshot wounds to the…

Mahmoud Houri died aged 27 in custody from multiple organ failure, a consequence of gunshot wounds sustained in 2002. The inquest examined whether appropriate care was provided on 21 August 2008 when he presented with vo…

general surgerygastroenterologymetoclopramide
VIChospital2018-02-26

Finding into death of Louis Oliver Tate

13y · Male·Malignant hyperthermia due to a reaction to an anaesthetic agent administered to…

Louis Tate, a 13-year-old with known allergies to cow's milk, raw egg, peanuts and tree nuts, died following anaphylaxis to breakfast provided in hospital. Despite reasonable medical management of the anaphylactic reacti…

paediatricsemergency medicinesystemcommunicationadrenaline
QLDhospital2019-09-05

Mrs MDF - Non-inquest findings

76y · Female·multisystem organ failure due to or as a consequence of ischaemic small intestin…

A 76-year-old woman presented to hospital with abdominal pain and was found on CT scan to have ischaemic colitis with signs of profound shock. The Consultant Surgeon decided on conservative management with fluid resuscit…

surgeryintensive carediagnosticcommunicationtramadol
NT2013-11-20

Inquest into the death of Sara Lorraine Hampel

21y · Female·Multiple organ failure as a result of overwhelming Streptococcus pyogenes (Group…

Sara Hampel, 21 years old, died from sepsis caused by necrotising fasciitis (Group A Streptococcus) on 14 October 2011, presenting 8 days post-partum with severe leg pain and multiple signs of sepsis. Critical failures i…

obstetricsemergency medicinediagnosticcommunicationparacetamol
VIChospital2023-10-30

Finding into death of BCT

2y · Unknown·Hypoxic-ischaemic encephalopathy following sepsis related to abdominal surgical …

BCT was a 2-year-old Aboriginal child with complex needs from a genetic disorder (CAMTA1 mutation) who died from hypoxic-ischaemic encephalopathy following sepsis related to bowel perforation after a percutaneous endosco…

gastroenterologyradiologydiagnosticcommunicationceftriaxone
WAhospital2012-10-05

Inquest into the Death of Rasmussen vaughn

15y · Male·Cerebral ischaemia in a young man with a blocked ventricular peritoneal shunt an…

…a registrar. Emergency neurosurgery at Princess Margaret Hospital on 17 November revealed complete distal catheter blockage, but irreversible cerebral ischaemia had already occurred. The coroner found the death was by mi…

general practicegeneral medicinediagnosticcommunicationlamotrigine
WAhome2012-06-29

Inquest into the Death of Operation Lantana

Toxicity from intravenous caesium, DMSO, and other substances administered as pa…

In May 2005, the Kathi Preston Memorial Health Centre (KPMHC) operated an unproven cancer therapy clinic from Dr B.'s home in Perth, Western Australia, administering intravenous treatment containing caesium, DMSO, and La…

general practiceoncologydiagnosticproceduralcaesium chloride
QLDhospitalPodcast2008-10-10

Maxfield, Annette

62y · Female·Haemorrhage caused by abdominoperineal excision of the rectum

A 62-year-old woman died of uncontrollable haemorrhage following an abdominoperineal excision of the rectum (APER) at a remote hospital. The coroner found the operation itself was inappropriate: performed for undiagnosed…

colorectal surgeryanaesthesiadiagnosticproceduralsevoflurane

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