Coronial

57 results for regional anaesthesia

VIChospital2015-04-02

Finding into death of Linda Elizabeth Parker

39y · Female·Hypoxic brain injury secondary to multiple hypovolaemic cardiac arrests from cat…

Linda Parker, aged 39, died from hypoxic brain injury following catastrophic postpartum haemorrhage from placenta increta during caesarean delivery. Critical lessons: (1) Placenta increta risk was not detected prenatally…

obstetricsanaesthesiadiagnosticdelay
WAhospital2013-05-01

Inquest into the Death of Squires, John Gregory

47y · Male·Pulmonary thromboembolism in association with deep vein thrombosis

A 47-year-old man from Carnarvon underwent elective laparoscopic cholecystectomy at Geraldton Regional Hospital on 31 August 2009 after a 5-hour coach journey that morning. The VTE Risk Assessment Form correc…

surgeryanaesthesiadiagnosticdelayheparin
WAhospital2025-12-23

Inquest into the Death of Karl Albert STEINHAUSER

30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…

…ehaviour and medication side effects created treatment challenges, the underlying systemic limitations in regional mental health infrastructure and inter-hospital transfer coordination were critical contributing factors.

psychiatryintensive caresystemdelayaripiprazole depot
QLDhospital2018-07-30

Khazaei, Hamid

24y · Male·Hypoxic-ischaemic encephalopathy, due to or as a consequence of cardiac arrest, …

Hamid Khazaei, an Iranian asylum seeker aged 24, died on 5 September 2014 after contracting a leg infection (Chromobacterium violaceum) on Manus Island while in immigration detention. His death was preventable and result…

emergency medicineinfectious diseasesdiagnosticcommunicationceftriaxone
WAhospital2013-11-29

Inquest into the Death of Jones, Wilma Ray

75y · Female·Abdominal infection following surgery (repair of recurrent umbilical hernia) - s…

Wilma Ray Jones, 75, died of abdominal infection and sepsis following uncomplicated umbilical hernia repair. Post-mortem revealed ischaemic bowel with infarction, likely caused by superior mesenteric artery occlusion tri…

general surgeryanaesthesiadelaysystemephedrine
VIChospital2021-09-21

Finding into death of AH

37y · Male·Mixed Drug Toxicity (Oxycodone, Quetiapine, Pregabalin and Clonazepam)

A 37-year-old man died from mixed drug toxicity (oxycodone, quetiapine, pregabalin, clonazepam) after ingesting unknown quantities of his own medications in an ED. He presented with trauma symptoms four days post-motor v…

emergency medicinetoxicologydiagnosticcommunicationoxycodone
VIChospital2015-07-15

Finding into death of Baby Mabel Windmill

0y · Female·Congenital Streptococcus agalactiae (Group B) pneumonia in the setting of compli…

…optimal clinical management decisions. Despite high BMI (48), Mrs Windmill was approved for delivery at a regional hospital without full antenatal risk counselling. During labour, an abnormal cardiotocograph (CTG) trace …

obstetricsanaesthesiadiagnosticmedicationbenzylpenicillin
VIC2013-10-21

Finding into death of Jaesok Lee

26y · Male·Multiple injuries from collision between semi-trailer and train at level crossin…

On 5 June 2007, a semi-trailer collided with a V/Line passenger train at the Kerang level crossing, killing 11 passengers. The driver had crossed this crossing hundreds of times without seeing a train, was familiar with …

emergency medicinetrauma surgerysystemdelay
SAhospital2000-07-21

Coroner's Finding: DRESCHLER Michelle Lee

27y · Female·Aspiration of gastric contents associated with persistent vomiting following gas…

A 27-year-old woman died from aspiration of gastric contents following a vertical-banded gastroplasty performed for morbid obesity. The surgeon created a stoma (opening) of 4-5mm diameter using a 27 French bougie, smalle…

general surgerygeneral practiceproceduralcommunicationdiazepam
TAShospital2024-06-21

Coroner's Finding: de-identified BP

16y · Male·transection of the liver and laceration of the inferior vena cava sustained in a…

A 16-year-old male died from transection of the liver and inferior vena cava laceration sustained in a quad bike accident. He was riding a single-rider ATV with a pillion passenger when he entered a left-hand corner too …

trauma surgeryemergency medicine
QLD2007-11-28

Tanner, Marjorie Joyce

Female·Coronary atherosclerosis with ischaemic small bowel and Alzheimer's disease

… earlier aggressive investigation for persistent obstruction symptoms, adequate ICU capacity planning for regional hospitals, and appropriate aeromedical retrieval resources.

general medicinesurgerydiagnosticsystemmetoclopramide
NSWhospital2016-03-11

Inquest into the death of Elsie COGHILL

0y · Female·Hypoxic ischaemic encephalopathy caused by multiple factors including lung abnor…

Elsie Coghill, a newborn, died from hypoxic ischaemic encephalopathy due to multiple factors including an underlying lung abnormality from antenatal distress, an undetected apnoeic episode during transfer, and undiagnose…

obstetricsneonatologycommunicationsystemoxytocin
VIChospital2015-06-12

Finding into death of Baby Chloe Lee Kellett

5y · Female·Cerebral hypoxic and ischaemic injury in a setting of clinical birth asphyxia

Chloe Kellett was born at 39 weeks gestation after induction of labour for rupture of membranes and group B streptococcus positivity. She was delivered by forceps in theatre for a non-reassuring cardiotocogram (CTG) trac…

obstetricspaediatricsdiagnosticcommunicationoxytocin
VIChospital2020-07-16

Finding into death of Lydia Maxfield

85y · Female·Multisystem failure complicating ischaemic heart disease and ischaemic bowel in …

Lydia Maxfield, 85, died 5 days after elective left total knee replacement at a private hospital from multisystem failure due to ischaemic heart disease and ischaemic bowel. Critical clinical lessons: (1) Multiple abnorm…

orthopaedic surgeryanaesthesiacommunicationsystemondansetron
VIChospital2019-01-24

Finding into death of Bryan Lindsay Cleeman

86y · Male·Complications post laparoscopic cholecystectomy

86-year-old man with acute gangrenous perforated cholecystitis underwent laparoscopic cholecystectomy on 2 October 2015, forty-two hours after admission. Severe bleeding from hepatic arterial branches required conversion…

general surgeryanaesthesiadelayasasantin
WAhospital2012-06-27

Inquest into the Death of LEE

37y · Male·Respiratory arrest in association with medication drug effect and alcohol intoxi…

David James Lee, a 37-year-old Aboriginal man with schizophrenia, died on 15 July 2007 at Port Hedland Regional Hospital from respiratory arrest associated with medication effect and alcohol intoxication. He arrived a…

emergency medicinepsychiatrymedicationcommunicationchlorpromazine
SAhospital2007-02-07

Coroner's Finding: ROBBINS Amy Louise

16y · Female·intra-abdominal haemorrhage due to ruptured spleen

A 16-year-old girl died from intra-abdominal haemorrhage due to ruptured spleen following a car rollover. She was transported by ambulance to the nearest hospital (Renmark) rather than the better-equipped Berri Hospital,…

trauma surgeryemergency medicinesystemdelay
NSWhospital2022-08-17

Inquest into the death of Robert Bischard

75y · Male·multifactorial causes on a background of ischaemic heart disease, generalised va…

Robert Bischard, a 75-year-old man with multiple complex comorbidities including coronary artery disease, chronic kidney disease, and diabetes, died five days after elective right total knee replacement surgery. The coro…

orthopaedic surgerycardiologydiagnosticsystemfurosemide
QLDhospital2007-01-10

West, Ian Leslie

26y · Male·bronchopneumonia following severe head injury

Ian Leslie West, a 26-year-old man with bipolar affective disorder, died from bronchopneumonia following severe head injury sustained when he fell from a hospital balcony on 31 December 2002. He had been admitted to Long…

psychiatryemergency medicinemedicationcommunicationacuphase
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…

A 77-year-old woman with complex comorbidities (atrial fibrillation, aortic stenosis, chronic renal impairment, emphysema) on Warfarin sustained a femur fracture and underwent ORIF on day 3 of admission (19 Nov 2009). Ke…

orthopaedic surgeryemergency medicinediagnosticsystemwarfarin

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