Coronial

453 results for anaesthesia

NSWhospital2014-09-26

Inquest into the death of AA

10y · Male·Hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…

A 10-year-old boy with severe obstructive sleep apnoea and morbid obesity died from hypoxic brain injury following cardiorespiratory arrest. Despite repeated medical interventions and explicit warnings that his condition…

respiratory medicineendocrinologycommunicationsystemmethadone
VIChospital2024-10-29

Finding into death of Shane Hughes

40y · Male·Acute hepatic and renal failure in the setting of postoperative haemorrhage foll…

A 40-year-old man with obesity, COPD, diabetes and hypertension died from acute hepatic and renal failure following postoperative haemorrhage after left radical nephrectomy for a 10cm renal cell carcinoma. The surgeon ap…

urologysurgeryproceduraldiagnosticmetaraminol
QLDhospital2018-09-21

Baby M

0y · Female·Intracranial and intrapulmonary haemorrhage due to traumatic head injury from fa…

Baby M died shortly after birth on 11 February 2016 at Gladstone Base Hospital from intracranial and intrapulmonary haemorrhage due to traumatic head injury from a fall, complicated by Group B Streptococcal sepsis. A nur…

obstetricsmidwiferydiagnosticmedicationantibiotics
NThospital2011-09-09

Inquest into the death of Linda Nha Tran

34y · Female·Catastrophic post-partum haemorrhage following caesarean delivery, secondary to …

A 34-year-old Vietnamese woman died from catastrophic postpartum haemorrhage following an elective caesarean delivery. Placenta accreta was discovered intraoperatively and managed with blood transfusion, uterotonic agent…

obstetricsanaesthesiamedicationcommunicationoxytocin
ACThome2019-06-04

Inquest into the death of Lauren Maree Johnstone

48y · Female·Combined toxic effect of prescription and non-prescription medications including…

Lauren Johnstone, aged 48, died from the combined toxic effects of prescription and non-prescription sedative medications including oxycodone, tramadol, codeine, zopiclone, doxylamine and fluoxetine. She had undergone mu…

general practicesurgerycommunicationsystemdoxylamine
NSWhospital2025-02-28

Inquest into the death of Heather Winchester

75y · Female·multiple organ failure due to severe anaemia secondary to blood loss post electi…

A 75-year-old woman died from multiple organ failure due to severe anaemia after elective hysterectomy surgery. Critical failures occurred: the surgical and anaesthetic teams held conflicting understandings about whether…

gynaecologyanaesthesiacommunicationsystem
VIChospital2016-05-19

Finding into death of Josip Dobrovoljski

62y · Male·Global cerebral ischaemia secondary to intra-operative hypotension following the…

A 62-year-old man died from global cerebral ischaemia following intra-operative hypotension after protamine administration during a cardiac ablation procedure. He had suffered a severe hypotensive reaction to protamine 8…

anaesthesiacardiologydocumentationcommunicationprotamine
QLDhospital2025-10-23

Inquest into the death of Shirley Elizabeth Haggett

78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…

78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). T…

anaesthesiaplastic and reconstructive surgerysystemdiagnosticmidazolam
VIChospital2025-05-13

Finding into death of Baby W

0y · Male·subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour

Baby W died within 40 minutes of birth from subgaleal haematoma and subarachnoid haemorrhage following a failed instrumental delivery for prolonged labour. The coroner identified critical missed opportunities in decision…

obstetricsneonatologydiagnosticproceduralclindamycin
NThospital2009-04-09

Inquest into the death of Georgia Rae Tilmouth

0y · Female·Organ failure caused by not receiving enough oxygen during labour (intrapartum h…

Georgia Rae Tilmouth was born at 35 weeks gestation after premature labour and died 13 hours later from perinatal asphyxia due to hypoxia during labour. The coroner found multiple deficiencies in obstetric care contribut…

obstetricsmidwiferydiagnosticcommunicationoxytocin
QLDhome2018-05-21

House, William John; White, Vanessa Joan; Smith, Jodie Anne and Milne, Daniel Keith

Unknown·acute fentanyl toxicity; acute oxycodone toxicity; multiple drug toxicity; opioi…

Four adults died from opioid overdoses (fentanyl and oxycodone) in Queensland between 2012–2014. All obtained prescriptions from multiple doctors ('doctor shopping') without effective detection. Systemic failures include…

general practicepain medicinediagnosticmedicationfentanyl
QLDhospital2008-09-12

Neville, Elise Susannah

10y · Female·Head injuries due to fall from a bunk bed

Elise Neville, aged 10, fell from a non-compliant bunk bed and sustained a head injury. At her first ED presentation to Caloundra Hospital at 3:25am, Dr D.—a junior house officer 19 hours into a 24-hour shift—failed to p…

emergency medicineneurosurgerydiagnosticcommunicationmannitol
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
QLDhospital2008-11-28

McVey, Oliver Steven

67y · Male·Complicated endotracheal tube insertion due to or as a consequence of recent clo…

Oliver Steven McVey, a premature twin born at 31 weeks gestation weighing 1036g, died from complications of endotracheal tube re-insertion at 67 days of age. Following successful surgical ligation of a patent ductus arte…

neonatologycardiothoracic surgeryproceduralcommunication
SAhospital2014-02-14

Coroner's Finding: RYAN John William and WALTON Patricia Dawn

Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…

Two obese patients died from hypoxic-ischaemic encephalopathy following cardio-respiratory deterioration post-operatively at a private hospital without overnight medical cover. John Ryan (54) deteriorated within hours of…

anaesthesiaorthopaedic surgerydiagnosticcommunicationmorphine
NSWhospital2017-12-22

Inquest into the death of Colin Parker

41y · Male·Complications of blunt force injuries of the head

Colin Parker, aged 41, suffered an unwitnessed fall with head injury while experiencing syncope from atrial fibrillation in early May 2014. He was admitted to Campbelltown Hospital but his serious intracranial pathology …

cardiologyemergency medicinediagnosticcommunicationenoxaparin
VIChospital2017-07-18

Finding into death of Lynsie Maree Everett

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 'red flag' indicators o…

emergency medicineinfectious diseasesdiagnosticsystemsalbutamol
SAhospital2009-12-31

Coroner's Finding: LYNN Matthew John

20y · Male·hypoxic encephalopathy

Matthew Lynn, aged 20, died from hypoxic encephalopathy after sustaining head injuries in a motor vehicle collision. While hospitalised in ICU, his endotracheal tube (ETT) became displaced around 12:20am on 23 January 20…

intensive careanaesthesiadiagnosticcommunicationpropofol
QLDhospital2007-11-23

Scholz, Karl David

31y · Male·Upper airway obstruction due to pharyngeal abscess caused by dental abscess, whi…

Karl Scholz, 31-year-old male, died from upper airway obstruction due to pharyngeal abscess originating from untreated dental infection. He presented with severe facial cellulitis and abscess following dental procedures …

intensive careanaesthesiadiagnosticcommunicationamoxicillin

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