Coronial

149 results for blood testing

VICcommunity2011-03-08

Finding into death of Andras Nagy

23y · Male·head injury resulting in acute left subdural haemorrhage and cerebral oedema fro…

…al boxers, leaving unregistered competitors like Nagy without medical oversight despite equivalent risk of bloodborne pathogen exposure.

emergency medicineneurosurgerysystem
SAhospital2005-08-30

Coroner's Finding: O'BRIEN Barbara Ann

57y · Female·right bronchopneumonia following hypoxic brain damage secondary to cardiac arres…

…w BSL levels. Direct admission to the psychiatric ward bypassing the Emergency Department, infrequent BSL testing, and lack of IV dextrose were identified as shortcomings, though expert opinion suggested these would unl…

psychiatryemergency medicinediagnosticcommunicationclozapine
QLDhospital2023-03-13

Timms, Peter John

71y · Male·Acute myeloid leukaemia due to transformation from chronic myelomonocytic leukae…

…tic leukaemia. He made over 40 health service requests while incarcerated, including repeated requests for blood tests starting in February 2020. A blood test ordered on 19 February 2020 was delayed 9 days and showed ab…

haematologypalliative caredelaydiagnosticoral antibiotics
VIChospital2015-12-04

Finding into death of Baby Kylie Hamilton

0y · Female·perinatal asphyxia

Baby Kylie Hamilton, a 3-day-old neonate, died from perinatal asphyxia following emergency Caesarean delivery during her mother's induced labour. The mother had gestational diabetes and the fetus showed concerning CTG ab…

obstetricsmidwiferypossibly preventable - management decision at 2.15pmoxytocin
NTcommunity2005-11-11

Inquest into the death of Damien Wayne

25y · Male·blunt head trauma occasioned when the deceased was thrown from a motor vehicle h…

…hicle accident while being pursued by Northern Territory Police. After failing to stop at a random breath testing station despite being significantly intoxicated (BAC 0.385%), police initiated a pursuit. Within Abbotts …

emergency medicineforensic medicineproceduralcommunicationalcohol
WAcommunity2005-05

Inquest into the Death of Adam David McKay

31y · Male·Pulmonary thromboembolism arising from deep vein thrombosis

…eteriorated rapidly in hospital and died despite thrombolytic therapy. The coroner found that preliminary testing (D-dimer or ultrasound) for DVT in December would likely have been diagnostic and allowed anticoagulation…

general practiceemergency medicinediagnosticcommunication
QLD2012-03-01

Law, Roslyn Amelia

20y · Female·Head injuries sustained in motor vehicle accident

… include: cannabis impairment may not be apparent to clinicians or police officers from observation alone; blood testing protocols must include drug screening for all seriously culpable drivers in fatal crashes, not jus…

trauma surgeryemergency medicinediagnosticsystemcannabis
NTcommunity2011-07-27

Inquest into the death of Marilyn Lalara

48y · Female·acute myocarditis resulting from systemic viral infection

…carditis earlier. On 4 April, she presented severely unwell with dramatically falling haemoglobin and high blood sugar. Although rapidly evacuated to Alyangula clinic where she was assessed as critically ill and awaitin…

emergency medicinecardiologydiagnosticdelayantibiotics
VIChospital2017-12-13

Finding into death of Lachlan Black

2y · Male·Group A beta Haemolytic Streptococcal septicaemia (invasive Group A Streptococca…

…rm the tachycardia; failure to examine and reassess after petechial rash appeared; and not taking baseline blood pressure until 8pm. Although antibiotics were eventually ordered at 8.30pm, there was a two-hour delay bef…

emergency medicinepaediatricsdiagnosticsystemparacetamol
QLD2017-08-04

Mrs H - Non-inquest findings

76y · Female·Acute renal failure due to dehydration due to upper gastrointestinal bleed

…onic pain was admitted to a small rural hospital on 1 April 2015 with haematemesis secondary to NSAID use. Blood tests were ordered on admission but not transported to the district hospital for testing until 3 April, de…

general medicinegastroenterologydiagnosticcommunicationibuprofen
SAhospital2003-03-12

Coroner's Finding: STOLL Ruth Sophie

71y · Female·massive acute haemolysis leading to severe anaemia and multi-system failure as a…

Ruth Stoll, 71, died from massive acute haemolysis and multi-system failure after receiving incompatible blood transfusions during aortic aneurysm repair. Pre-operative blood samples from Stoll and another patient (Ko…

cardiothoracic surgeryanaesthesiadiagnosticprocedural
NSWhospital2011-11-11

Coroner's Finding: John Reginald Beech

64y · Male·Postoperative intra-abdominal bleeding from pancreatic artery injury and its con…

… that was not recognized initially. The anaesthetist incorrectly diagnosed anaphylaxis and failed to order blood tests, though he sought ICU input. The surgeon waited for results but then prioritized another patient's o…

anaesthesiacolorectal surgerydiagnosticdelaymorphine
WAhospital2021-11-29

Inquest into the Death of Miss T (Name Subject to Suppression Order)

16y · Female·acute abdominal obstruction secondary to adhesions associated with severe pelvic…

…her second presentation on 24 December, she was discharged home without a clear diagnosis despite abnormal blood tests (elevated white cell count, raised inflammatory markers, metabolic acidosis) suggestive of possible …

emergency medicinegeneral practicediagnosticsystemcannabis
VIChospital2018-06-14

Finding into death of Ian John Gilbert

77y · Male·Complications of methotrexate toxicity in a man with chronic renal impairment, c…

…oxicity after a GP prescribed it at an inappropriate daily dose (5mg daily) for psoriasis without baseline blood tests. The dispensing pharmacist recognized the dangerous dose, called the doctor, but ultimately dispense…

general practicepharmacydiagnosticmedicationmethotrexate
NSWhospital2018-12-03

Inquest into the death of Troy Almond

1y · Male·Septicaemia due to Streptococcal (Beta Haemolytic Group A) infection

…ng signs of toxicity and persistent tachycardia throughout his 4-hour ED stay, Troy was discharged without blood tests to investigate possible bacterial infection. He deteriorated overnight and died from Group A Strepto…

emergency medicinepaediatricsdiagnosticsystemparacetamol
VIChospital2012-06-22

Finding into death of Sebastian Hewitt

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

…old. Critical clinical lessons emerged regarding neonatal assessment: persistently pale newborns with cord blood pH 7.02 and hypothermia require investigation for anaemia and foetal-maternal haemorrhage, and repeat bloo…

obstetricspaediatricsdiagnosticdelay
WAhospital2023-06-29

Inquest into the Death of Child R (Name Subject to Suppression Order)

11y · Female·Complications of E. coli sepsis in association with intestinal obstruction due t…

…al until 11:40am when her condition was already critical; and unavailable age-related reference ranges for blood test interpretation. The child remained in the ward rather than the Emergency Department despite being uns…

paediatricsemergency medicinediagnosticcommunicationmacrogol
NSWhospital2009-06-12

Coroner's Finding: Rebecca Murray

29y · Female·Multisystem organ failure following postpartum haemorrhage due to atonic uterus

…oner found her death preventable. Key clinical failures: (1) Hospital policy of not ordering pre-operative blood group/hold/cross-match for emergency caesareans, resulting in delayed transfusions; (2) Inadequate handove…

obstetricsanaesthesiasystemcommunicationoxytocin
QLD2007-09-14

Waugh, Cappur William Embling

17y · Male·Complications of head injury sustained in a single vehicle roll-over; cardioresp…

…sed but not on the driver, an important investigative gap. The coroner recommended mandatory breathalysing/blood testing of all drivers involved in serious collisions and improved communication with distressed families …

NSWcommunity2023-08-01

Inquest into the death of Peter Gretton

64y · Male·Complications of metformin toxicity on a background of undiagnosed renal impairm…

…gnition of severe metabolic derangement; incomplete vital sign documentation; failure to perform troponin testing; and delayed physician attendance. RN Magazini did not call an ambulance when indicated by guidelines des…

emergency medicinecardiologydiagnosticcommunicationmetformin

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