Coronial

77 results for early septic shock

WA2013

Inquest into the Death of Ms D

39y · Female·Septic shock and nosocomial pneumonia secondary to pentobarbital (Nembutal) over…

…onality traits died by suicide in Mexico following a pentobarbital overdose on 28 April 2008, resulting in septic shock and nosocomial pneumonia. She had been an inpatient at the Mother and Baby Unit (MBU) with involunta…

psychiatryintensive caresystemdelaypentobarbital
VIChospital2016-12-12

Finding into death of Hugo Edward Byard Gardiner

3y · Male·Streptococcus pyogenes group A pneumonia

…topsy confirmed Streptococcus pyogenes group A pneumonia with pleural effusions. Clinical lessons include: early recognition of severe sepsis in children requires lower diagnostic thresholds; concerning vital signs warr…

general practicepaediatricsdiagnosticcommunication
WAhospital2025-04-17

Inquest into the Death of Colin Stanley Francis NICHOLSON

69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…

Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at mult…

haematologygeneral practicediagnosticcommunicationparacetamol
SAhospital2003-11-05

Coroner's Finding: MARTIN Julie Anne

38y · Female·peritonitis with septic shock secondary to perforation of the gastrointestinal t…

…e indicating acidosis). (2) The patient was inappropriately discharged at 3:30am without diagnosis while clearly unwell, to a facility with no medical staff on duty. (3) Coffee-ground vomitus was documented but not prop…

anaesthesiaemergency medicinediagnosticcommunicationsuxamethonium
VIChospital2025-07-30

Finding into death of YTR

78y · Female·Complications of prolonged immobility and malnutrition in a woman with retroperi…

A 78-year-old woman with schizophrenia, depression, and undiagnosed retroperitoneal lymphoma died from septic shock complicating severe pressure ulcers, malnutrition, and dehydration. She had been immobile on a couch…

geriatric medicineintensive caredelaysystemasenapine
NSWhospital2022-05-30

Inquest into the death of Alex BRAES

18y · Male·Multi organ failure due to sepsis from a Group A streptococcus infection

… vital signs should be routine for all ED patients; (2) vital signs were not taken on 20 September despite early clinical indicators (patient reported knee felt hot), missing an opportunity to prompt infection investiga…

emergency medicineinfectious diseasessystemdelayceftriaxone
SAhospital2020-06-18

Coroner's Finding: THOMPSON Wayne Robert McInnes

33y · Male·Multi-organ failure due to sepsis on a background of severe ischaemic cardiomyop…

…me detention, and progressive cardiac deterioration. He presented to hospital on 30 November 2016 severely septic with cellulitis, requiring intensive support including ECMO and mechanical ventilation. Despite maximal me…

cardiologyintensive carewarfarin
VIChospital2023-02-22

Finding into death of Christine Ann Stephen

67y · Female·Intra-abdominal sepsis complicating an anastomotic leak following elective surge…

…t surgeon and intensivist did not attend the patient in person despite concerning clinical trajectory; and early diagnosis of sepsis was not made. While experts disagreed on whether earlier interventions would have chan…

colorectal surgeryintensive carecommunicationdelaynoradrenaline
WAhospital2023-02-22

Inquest into the Death of Aishwarya Aswath CHAVITTUPARA

7y · Female·multiorgan failure due to fulminant sepsis (Streptococcus pyogenes)

…d parental concern. By the time sepsis was recognised at 7.30pm during resuscitation, she was irreversibly septic with severe acidosis. Expert evidence indicates earlier recognition and treatment between 5.30-6.00pm migh…

emergency medicinepaediatricsdiagnosticcommunication
WAhospitalAugust 2023

Inquest into the Death of Justin DOBSON

46y · Male·sepsis following haemorrhoidectomy

…0 am on 18 July, showing hypotension, tachycardia, and urinary retention. Clinical and laboratory clues of early sepsis—raised creatinine and urea, elevated heart rate and low blood pressure in a post-operative patient—…

general surgerycolorectal surgerydiagnosticcommunicationmetronidazole
WAhospital2016-05-18

Inquest into the Death of Janice May SAULYS

69y · Female·multi-organ failure due to sepsis of unknown origin

…epsis of unknown origin. She presented to a rural hospital on 28 June 2012 with vomiting, dehydration, and early renal failure. Despite appropriate investigations ordered by her GP and attempted transfer to a tertiary f…

emergency medicinegeneral practicesystemdelay
VIChospital2024-01-23

Finding into death of Baby T S

20y · Male·Group A streptococcus pneumonia (invasive Group A Streptococcus infection of the…

…re throat, no respiratory distress, and clear chest. However, groaning and the atypical rash may have been early iGAS indicators. The case highlights the diagnostic challenge of rapidly progressive iGAS in young childre…

general practiceemergency medicineamoxicillin
VIChospital2024-09-26

Finding into death of FH C

11y · Male·Sepsis

An 11-year-old boy with autism spectrum disorder (ASD level 3), ADHD, and obesity died from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was dischar…

emergency medicinepaediatricsdiagnosticcommunicationrisperidone
VIC2017-10-31

Finding into death of Andrew John Harman

49y · Male·Complications of heatstroke; Hyperthermia

…ysical activity in warm, humid conditions (28-29°C) while wearing heavy protective equipment. He struggled early in the ride, became unable to access water from his blocked CamelBak pouch, and eventually collapsed with …

emergency medicineintensive caredelay
SAhospital2017-04-07

Coroner's Finding: MAYELL Edward John

83y · Male·pneumonia and severe acute respiratory distress syndrome caused by Legionella ba…

…ing aspiration rather than atypical organisms; (5) inappropriate triage and lack of vital sign monitoring. Early diagnosis and appropriate broad-spectrum antibiotics on 16 September afternoon would likely have improved …

emergency medicinegeneral practicediagnosticmedicationceftriaxone
WAhospital2022-10-05

Inquest into the Death of David Arthur RICE

75y · Male·acute bronchopneumonia in a man with comorbidities

…ensive medical care that exceeded community standards. However, system failures prevented consideration of early release via Royal Prerogative of Mercy: briefing notes required by policy were not sent when he was design…

general medicinecardiologysystemapixaban
QLDhome2020-03-11

Roulant, Daniel Christopher

22y · Male·Meningococcal meningitis and sepsis

…rapidly deteriorate and mimic viral illness; (2) young adults with meningococcal carriage may have minimal early warning signs; (3) rapid progression from mild symptoms to sepsis-related death can occur within 24 hours;…

general practiceinfectious diseases
SAhospital2024-05-22

Coroner's Finding: Kolega, Sime

54y · Male·multi-organ failure and sepsis complicating fulminant pneumonia with empyema (op…

…mmencement would likely have altered the outcome. The main clinical lesson is recognising severe pneumonia early and ensuring patients have timely access to investigation and treatment, particularly when standard pathol…

general practiceemergency medicinedelaysystemflixotide
SA2011-11-04

Coroner's Finding: Sleeping Rough Inquest

Multiple: pneumonia with cardiomyopathy (Kugena female); septic shock from pneum…

…uld be treated as a serious health problem requiring rehabilitation facilities located within communities; early intervention for alcohol abuse is critical in Aboriginal populations with high disease burden; sobering-up…

emergency medicinerespiratory medicinesystemdelayalcohol
QLDrural hospital2020-05-08

FD - Non-inquest findings

68y · Female·Sepsis (Enterobacter cloacae) due to peritonitis as a consequence of leaking per…

…rt without RSQ consultation despite clinical instability. She arrested during ambulance transfer and died. Early recognition of sepsis, appropriate escalation, and consultation with retrieval services could have improve…

gastroenterologyemergency medicinediagnosticcommunicationaugmentin duo

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