Coronial

47 results for hypoxic organ failure

VIChospital2015-12-10

Finding into death of Dane Alexander Hortle

2y · Male·Tramadol toxicity in the setting of adenotonsillectomy in a child with Pierre Ro…

…peutic concentrations. The child deteriorated overnight with respiratory depression, seizures, and severe hypoxic-ischaemic brain injury, leading to death despite intensive care. Key clinical failures included: the pres…

ENT surgerypaediatric surgerymedicationcommunicationtramadol
NThospital2009-05-28

Inquest into the death of Declan McConville

0y · Male·acute hypoxic damage caused by shoulder dystocia during delivery

…August 2007. He was stuck in the birth canal for approximately 15 minutes before delivery, causing severe hypoxic brain injury. He died 8 days later from acute hypoxic damage and multiple organ failure. The coroner foun…

obstetricspaediatricsproceduralsystemoxytocin
NSWcustody2022-07-21

Inquest into the death of Richard Navarro

43y · Male·Hypoxic Ischaemic Encephalopathy due to out of hospital cardiac arrest, secondar…

…ith severe obstructive sleep apnoea (OSA), morbid obesity, hypertension, and recurrent pneumonia, died of hypoxic ischaemic encephalopathy following cardiac arrest while in custody at Silverwater Correctional Centre. He…

respiratory medicinecardiologysystem
QLD2011-11-24

Choi, Seongeun; Park, Sang Won

Unknown·Ms Choi: hypoxic brain damage due to drowning/immersion due to rafting accident;…

… and flip. Both occupants became entrapped underwater. Ms Choi was rescued and received CPR but died from hypoxic brain damage five days later. Mr Park remained entrapped and died from drowning with crush injuries. The …

emergency medicineintensive caresystemcommunication
QLDhome2007-03-22

Dee, Fiona Jane

32y · Female·Hypoxic brain injury due to a combination of factors arising from subdural haema…

A 32-year-old fit and healthy woman died from hypoxic brain injury following complications of spinal anaesthesia for caesarean section. She developed a subdura…

obstetricsanaesthesiacommunicationdiagnosticcarbamazepine
VIChospital2024-08-14

Finding into death of Gayle Dianne Ireland

63y · Female·Sepsis with multiorgan failure in the setting of limb cellulitis complicating a …

…red inadequate; she was discharged with advice to see her GP in one week. She returned on 24 January 2024 hypoxic and hypotensive with sepsis, requiring ICU admission. Despite treatment with antibiotics and supportive c…

emergency medicineintensive carediagnosticdelayceftriaxone
SA2023-05-12

Coroner's Finding: Morrison, Wayne Fella

29y · Male·Hypoxic ischaemic encephalopathy and multi-organ failure due to out of hospital …

…es; and timely CPR (ideally within 4 minutes) significantly improves survival. The coroner found systemic failures in the department's training, supervision, record-keeping, and admission processes, but could not attrib…

emergency medicineintensive caresystemdelay
QLDhospital2025-10-01

Non-inquest findings into the death of Mr S

26y · Male·Multi-organ failure due to pneumococcal septic shock

…coccal infection. Critical deterioration occurred at 1:30am on 18 February when he became tachycardic and hypoxic, requiring medical review and antibiotics initiation per sepsis pathway. This review did not occur, causi…

emergency medicineinfectious diseasesdiagnosticdelayantacid
QLD2021-08-20

Caramin, Olivier Max - Non-inquest findings

27y · Male·multiple organ failure due to or as a consequence of heat stroke

Olivier Caramin, a 27-year-old Belgian national on a working holiday visa, died from heat stroke while picking pumpkins on 31 October 2017 in Far North Queensland. He was just three days into farm work without proper acc…

occupational and environmental healthemergency medicinesystemdiagnostic
ACThospital2025-02-26

Inquest Into The Death Of Jessica Hilary Bovill

43y · Female·Severe diffuse hypoxic brain injury caused by administration of supratherapeutic…

A 43-year-old woman died from severe diffuse hypoxic brain injury caused by excessive sodium bicarbonate administration during treatment of amitriptyline over…

emergency medicinetoxicologymedicationcommunicationamitriptyline
SAhospital2011-08-05

Coroner's Finding: LEONARD Emily Ruth and HILLMAN Glenys Anne

Female·Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perfor…

…ury was not recognized intraoperatively and only became apparent 6 days post-discharge, resulting in multi-organ failure and death. Mrs Hillman (67) underwent open surgery on 28 May 2009; a small bowel perforation was i…

gynaecologyintensive carediagnosticproceduralheparin
NSW2011-07-01

Coroner's Finding: Michael Peter Magro

40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…

Michael Peter Magro, a 40-year-old male inmate at a correctional facility, died on 27 December 2008 from hypoxic brain injury following cardiac disease and severe pneumonia. Critical failures in prison healthcare were …

correctional healthgeneral practicediagnosticcommunicationmethadone
QLDhospital2024-04-22

Non-inquest findings into the death of Lenore

48y · Female·Hypoxic ischaemic encephalopathy due to pulmonary thromboembolism due to deep ve…

…fety-netting. The patient collapsed with pulmonary embolism on return to the rural hospital and died from hypoxic ischaemic encephalopathy. The coroner found that timely VTE risk assessment and prophylaxis would have si…

emergency medicineorthopaedic surgerydiagnosticsystemoxycodone
VIChospital2025-12-01

Finding into death of Larelle Sheridan Dean

51y · Female·Multiorgan failure in the setting of WHO Class III obesity, chronic excessive al…

A 51-year-old woman with WHO Class III obesity, chronic alcohol consumption, and anaemia died of multiorgan failure following admission with community-acquired pneumonia and respiratory failure. She presented with …

general medicineemergency medicinehydromorphone
VIChospital2012-06-22

Finding into death of Sebastian Hewitt

2y · Male·Perinatal asphyxia leading to cerebral anoxia and subsequent multi-organ failure

…tum haemorrhage and abnormal CTG traces, died from perinatal asphyxia leading to cerebral anoxia and multi-organ failure at 3 days old. Critical clinical lessons emerged regarding neonatal assessment: persistently pale …

obstetricspaediatricsdiagnosticdelay
QLDhospital2021-11-01

Masoumali, Omid

24y · Male·Multiple organ failure due to or as a consequence of severe thermal burns

… self-immolating at the Nibok settlement. He was airlifted to Brisbane but died on 29 April 2016 from multiorgan failure. Critical clinical lessons include: (1) inadequate mental health triage—his self-referral for psyc…

plastic and reconstructive surgeryintensive carecommunicationsystem
SA2025-05-20

Coroner's Finding: Pham, Duy Ngoc

35y · Male·multiple organ failure due to out-of-hospital circulatory arrest due to perforat…

35-year-old male died from multiple organ failure following out-of-hospital cardiac arrest caused by perforated duodenum. He was in police custody f…

emergency medicinegeneral practicedelaycommunicationmethamphetamine
WA2016-10-10

Inquest into the Death of Hayder SAYED

30y · Male·Acute cardiac failure in association with severe ischaemic heart disease seconda…

A 30-year-old Afghan asylum seeker died from acute cardiac failure due to severe coronary atherosclerosis while in immigration detention. He had developed a large anterosep…

cardiologyemergency medicinemirtazapine
VIChospitalPodcast2021-12-10

Finding into death of Peta Hickey

43y · Female·Multisystem organ failure and hypoxic/ischaemic encephalopathy following anaphyl…

Peta Hickey, a 43-year-old company executive with no cardiac history, died from anaphylaxis to CT coronary angiogram contrast after her employer commissioned an inappropriate screening program. The referral lacked clinic…

radiologyemergency medicinediagnosticmedicationomnipaque 350 contrast dye
WAhospital2016-09-08

Inquest into the Death of Anandakumar SELLAKATHIRKGAMAN

38y · Male·hypoxic brain injury and organ failure following compression of the neck (hangin…

…pecialist psychiatric review or escalation to on-call psychiatry. Critical missed opportunities included: failure to escalate his case despite three self-harm attempts and asylum seeker status; lack of communication abo…

psychiatryemergency medicinediagnosticcommunicationdiazepam

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