Coronial

45 results for debridement

VIChospital2020-11-25

Finding into death of Eoghan Jerome Arnold

42y · Male·Hypoxic ischaemic brain injury secondary to cardiac arrest caused by massive pul…

A 42-year-old man died from hypoxic ischaemic brain injury following cardiac arrest due to a massive pulmonary embolism. He sustained a tibial fracture in a motor vehicle accident and underwent external fixation. He deve…

orthopaedic surgeryanaesthesiasystemenoxaparin
NSWhospital2021-11-19

Inquest into the death of Emiliana OBUSAN

1y · Female·unrecognised oesophageal intubation

A 19-month-old girl died from unrecognised oesophageal intubation during anaesthesia for finger laceration repair. The anaesthetic team failed to recognise multiple clinical indicators of tube misplacement: absence of pe…

anaesthesiaorthopaedic surgerydiagnosticcommunicationfentanyl
TAShospital2025-01-20

Coroner's Finding: Lowe, Wayne Anthony

58y · Male·multiorgan failure due to sepsis resulting from repeatedly fractured left humeru…

Wayne Anthony Lowe, aged 58, died of multiorgan failure due to sepsis following repeated humeral fractures sustained in falls. He was admitted with a right proximal humeral fracture from an intoxicated fall, discharged a…

orthopaedic surgerygeneral medicinesystemdelay
SAhospital2013-08-19

Coroner's Finding: WEEKS Ronald Geoffrey

84y · Male·respiratory failure due to hospital-acquired pneumonia

Ronald Geoffrey Weeks, aged 84, died of respiratory failure due to hospital-acquired pneumonia following a hip fracture sustained in a fall at James Nash House psychiatric facility. He was serving an 8-year sentence for …

geriatric medicineorthopaedic surgerysystemdelay
QLDhospital2016-11-14

Ms H - non-inquest findings

23y · Female·Necrotising retroperitoneal fasciitis due to acute perforated gangrenous appendi…

Ms H, a 23-year-old with Asperger's syndrome and intellectual impairment under OPG guardianship for healthcare decisions, presented to Redcliffe Hospital ED with abdominal pain, vomiting and diarrhoea. Despite clinical c…

emergency medicinesurgerysystemdiagnosticparacetamol
VIChome2026-03-04

Finding into death of Carol Fay Slade

54y · Female·Severe burns sustained in a house fire (palliated)

Carol Fay Slade, a 54-year-old woman with acquired brain injury from a 2003 motorcycle accident and mobility limitations, died from severe burns sustained in a house fire at her public housing property in Shepparton. The…

emergency medicineintensive caresystemmethadone
VICaged care2019-07-31

Finding into death of Hong Tay

63y · Male·Sepsis in a man with complicated peripheral vascular disease

Hong Tay, a 63-year-old man with extensive peripheral vascular disease, diabetes, and prior amputations, died from sepsis in an aged care facility following a cervical spine fracture sustained in a fall. After conservati…

geriatric medicinepalliative carecommunicationsystemfentanyl
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
ACThospital2019-11-06

Inquest into death of THEADORA ZAAL

75y · Female·cardiac arrest in the context of aortic stenosis (moderate to severe), coronary …

…(aortic stenosis, coronary artery disease, left ventricular hypertrophy) underwent elective ankle ulcer debridement surgery. She developed refractory hypotension post-operatively. Although her Modified Early Warning Sco…

anaesthesiasurgerydiagnosticsystem
WAhospital2024-08-28

Inquest into the Death of Matthew John PICKIN

56y · Male·Complications, including sepsis, of left leg infection (operated), in a man with…

Matthew John Pickin, a 56-year-old prisoner with metastatic lung adenocarcinoma, died from sepsis complicating a left leg infection. His lung cancer was appropriately investigated following haemoptysis in October 2021, w…

respiratory medicineoncologysystemdexamethasone
NSWhospital2019-03-01

Inquest into the death of Stephen Kline

51y · Male·Pulmonary thromboemboli due to deep vein thrombosis on a background of a leg bur…

Stephen Kline, a 51-year-old Aboriginal man, died from pulmonary thromboembolism due to deep vein thrombosis following a leg burn wound sustained when NSW Police deployed a taser during a confrontation on 8 March 2016. H…

plastic and reconstructive surgerypsychiatrydiagnosticsystemheparin
SAcommunity2005-10-13

Coroner's Finding: MURRAY John Matthew

35y · Male·pulmonary thromboembolism due to left deep calf vein thrombosis complicating lef…

John Matthew Murray, aged 35, died from pulmonary thromboembolism caused by deep vein thrombosis following a severe motorcycle accident that resulted in pelvic and leg fractures. He was treated surgically at Royal Adelai…

orthopaedic surgeryemergency medicinemedicationsystemheparin
SAhospital2000-07-21

Coroner's Finding: HOWIESON Julie Ann

43y · Female·sepsis secondary to extensive acute peritonitis following perforation of small b…

43-year-old woman died from sepsis and necrotising fasciitis following small bowel perforation during laparoscopic tubal ligation. She was at high risk due to previous abdominal surgeries and adhesions. A 4-5mm perforati…

gynaecologyanaesthesiadiagnosticdelay
SAhospital2005-10-13

Coroner's Finding: MURRAY John Matthew

35y · Male·pulmonary thromboembolism due to left deep calf vein thrombosis complicating lef…

John Matthew Murray, aged 35, died of pulmonary thromboembolism complicating pelvic and leg fractures sustained in a motorcycle accident. He was admitted to Royal Adelaide Hospital and underwent extensive orthopaedic sur…

orthopaedic surgerytrauma surgerymedicationsupervisionheparin
QLDcommunity2016-12-08

Floyd, Leah Elizabeth

48y · Female·Sepsis due to pulmonary and cutaneous infections, with urinary tract infection a…

A 48-year-old tetraplegic woman died from sepsis originating from a necrotic sacral pressure wound. Multiple system failures contributed: inadequate pressure sore prevention at the disability care provider (air mattress …

neurologypsychiatrycommunicationsystemdiazepam
QLDaged care2024-10-22

Non-inquest findings into the death of MH, an aged care resident

98y · Female·Sepsis due to sacral pressure ulcer complicated by osteomyelitis against a backg…

…ufficient general practitioner involvement during terminal decline. Earlier antibiotic treatment, wound debridement, and consideration of palliation may have altered outcomes.

geriatric medicinegeneral practicediagnosticsystemwarfarin
VIChospital2025-10-28

Finding into death of Christopher Gerard McIntosh

54y · Male·Respiratory failure secondary to prolonged ventilation for management of sepsis …

Christopher McIntosh, a 54-year-old man with Type II diabetes and chronic foot ulcers, died from respiratory failure secondary to sepsis arising from an infected foot ulcer requiring above-knee amputation. He was incarce…

infectious diseasesvascular surgerydiagnosticsystemantibiotics
SAhospital2011-08-05

Coroner's Finding: SEMMLER Howard Malcolm

60y · Male·cardiorespiratory failure due to malignant pleural effusion due to metastatic ma…

A 60-year-old man with diabetes presented with a plantar heel ulcer in March 2007 that was initially treated as a diabetic foot ulcer. The lesion failed to heal over 16 months despite standard care including wound dressi…

general practiceorthopaedic surgerydiagnosticdelay
VIChospital2012-09-11

Finding into death of Robert Anderson

50y · Male·Complications of right buttock necrotising fasciitis secondary to chronic right …

50-year-old male with chronic pain from jockey injuries became dependent on morphine. General practitioner prescribed intramuscular (IM) morphine for self-administration at home from 2005–2007 at doses of 120–240mg daily…

general practicepsychiatrydiagnosticmedicationmorphine sulphate
QLDhospital2011-06-09

Tranby, James Errol

64y · Male·necrotising fasciitis precipitated by a fishbone perforating his rectum, leading…

James Tranby, a 64-year-old Indigenous diabetic prisoner, presented with a fish bone lodged in his rectum on 3 December 2008. Following removal on 5 December, he developed progressive sepsis leading to necrotising fascii…

general surgerycolorectal surgerydiagnosticdelayinsulin

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