60y · Male·Pulmonary Thromboembolism
Mr McCormack, a 60-year-old man with Huntington's disease and epilepsy living in supported disability accommodation, died from pulmonary thromboembolism following hospitalization for seizures. He was admitted to Austin H…
15y · Male·right haemothorax due to lacerations of right lung
…riate: rescue teams extracted him from severe entrapment within 100 minutes; pre-hospital care including intubation was excellent; hospital resuscitation in the Emergency Department was well-managed with appropriate use …
22y · Male·Mixed Diflunisal and Buproprion (Zyban) toxicity
…direct consultation), delayed medical review (45 minutes), delayed decontamination by 1.5 hours, delayed intubation despite seizures and declining consciousness, and failure to recognise the multi-drug overdose despite p…
87y · Female·Pulmonary artery rupture complicating pulmonary artery catheter insertion in a w…
…od was observed in her oral cavity—a known clinical sign of PAC-related pulmonary artery injury. Despite intubation and resuscitation attempts, she developed massive pulmonary haemorrhage, hypoxia, and cardiac arrest. An…
45y · Male·Aspiration pneumonia with acquired brain injury as a contributing factor
Marco Virgona, a 45-year-old man with acquired brain injury and epilepsy, died from aspiration pneumonia at Frankston Hospital on 23 May 2017. He initially presented to Ambulance Victoria in the morning with vomiting and…
39y · Male·Hypoxic brain injury due to respiratory obstruction following surgery for dental…
…operatively, progressive airway swelling developed rapidly, causing complete obstruction. The initial re-intubation attempt was oesophageal rather than tracheal, a critical error not immediately recognised due to apparen…
63y · Female·Complications following sedation for percutaneous endoscopic gastrostomy (PEG) t…
…ng hospitalisation for dehydration. During attempted PEG insertion on 27 June, she desaturated requiring intubation and ICU admission. The clinical lesson is the need for careful risk stratification before sedation in pa…
13y · Male·Malignant hyperthermia due to a reaction to an anaesthetic agent administered to…
…sonable medical management of the anaphylactic reaction with multiple doses of intramuscular adrenaline, intubation became necessary. The critical lesson is systemic food safety failure: no written allergen policy existe…
52y · Male·Coronary Atherosclerosis
…m outage preventing access to medical history, nursing staff provided competent emergency care including intubation during ambulance transport. Advanced life support continued during hospital admission but was unsuccessf…
48y · Male·undetermined
A 48-year-old man with schizoaffective disorder, poorly controlled diabetes, sleep apnoea, obesity and cardiomegaly died unexpectedly at a rural hospital following acute psychotic agitation. He had absconded from a menta…
67y · Male·Complicated endotracheal tube insertion due to or as a consequence of recent clo…
…on difficulties in the immediate post-operative period. A 3.0mm endotracheal tube (ETT) was selected for intubation; the coroner noted guidelines recommended 3.5mm for babies over 2kg. Oliver deteriorated with rising CO2…
52y · Male·Polypharmacy overdose of amitriptyline and doxylamine in the context of underlyi…
…ned in prone position to enable sedation with ketamine and midazolam. He deteriorated acutely, requiring intubation and ultimately died. Medical care was appropriate throughout. The coroner found restraint was clinically…
68y · Female·Anaphylactoid reaction to intravenous CT scan contrast medium leading to cardior…
…tration was delayed when it should have been given immediately as the mainstay of anaphylaxis treatment; intubation required multiple attempts; and fluid resuscitation was inadequate. The coroner found the decision to us…
81y · Male·Community acquired pneumonia in a man with acute on chronic renal failure
…re. He presented to hospital on 25 April 2023 with respiratory failure and was admitted to ICU requiring intubation and multi-organ support. He was extubated briefly but required re-intubation and died on 6 May 2023. Cli…
0y · Male·Sudden Infant Death Syndrome (SIDS) against a background of sub-glottic stenosis…
Brendan Scott Kay, a 104-day-old ex-premature infant with sub-glottic stenosis from prolonged neonatal intubation, died suddenly in his parents' car during transfer home from Brisbane to Tully. The stenosis had been in…
1y · Male·hypoxic brain damage due to laryngeal obstruction from foreign body (metal screw…
An 11-month-old boy died from hypoxic brain damage following aspiration of a 2cm metal screw that lodged in his larynx. The child was left briefly unsupervised at home when he ingested the screw and began choking. Parent…
59y · Male·Massive aspiration in the setting of intubation following complications of sever…
A 59-year-old man with treatment-resistant schizophrenia on long-term clozapine therapy died from massive aspiration following a severe ileus of unknown aetiology. He had documented constipation managed with laxatives, t…
52y · Male·Acute Respiratory Distress Syndrome
Neville Towner, a 52-year-old man serving a life sentence, died from acute respiratory distress syndrome (ARDS) secondary to severe community-acquired pneumonia. He presented to hospital on 15 June 2018 with respiratory …
57y · Male·Combined effects of aspiration pneumonia and epilepsy (with cerebral palsy as un…
Mr Vincenzo Mario Chiarello, a 57-year-old man with cerebral palsy, intellectual disability, and epilepsy living in specialist disability accommodation, died from combined aspiration pneumonia and epilepsy complicated by…
36y · Female·Complications of pneumonia and pulmonary emphysema with bullae formation; respir…
A 36-year-old woman with congenital chest wall abnormality, scoliosis, and difficult intubation history presented to a rural hospital with community-acquired pneumonia and sepsis. She had multiple 're…
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