76 results for “induction procedures”
acute myeloid leukaemia
…to or hastened the deaths. The key clinical lessons include the importance of robust clinical governance procedures for protocol accuracy, timely error detection and communication across facilities, and appropriate adver…
21y · Male·complications of ligature compression of the neck (hanging)
Sarwan Al Jhelie, a 21-year-old Iraqi-born man in immigration detention, died by suicide on 5 September 2018 after hanging himself. He had a history of trauma, depression, drug abuse, and prior self-harm and overdose att…
27y · Male·multiple organ failure due to or as a consequence of heat stroke
Olivier Caramin, a 27-year-old Belgian national on a working holiday visa, died from heat stroke while picking pumpkins on 31 October 2017 in Far North Queensland. He was just three days into farm work without proper acc…
63y · Male·complications of an inverted positional event (asphyxia from airway occlusion)
A 63-year-old man with previous stroke and left-sided paralysis fell headfirst into his bedside drawer while attempting to open it from his motorised wheelchair. He became trapped with his airway occluded. An enrolled nu…
28y · Female·Anaphylactic reaction to anaesthetic drug (suxamethonium), with underlying coron…
…Despite competent initial airway management, she developed severe respiratory distress immediately after induction, subsequently progressing to cardiovascular collapse and death. Expert analysis concluded anaphylaxis to…
72y · Male·Choking on a food bolus
…aged care facilities must provide mandatory staff training in dysphagia management and choking emergency procedures; residents with stroke, dementia, and swallowing disorders require regular speech pathology review; feed…
68y · Male·head injury from crush trauma between forklift mast components
A 68-year-old experienced forklift operator died after being crushed between the mast and operator's cage of a TCM Series 700 forklift at a trucking business. The evidence suggests Mr. Rowe's feet slipped on the forklift…
25y · Female·Ligature Compression of the Neck (Hanging)
… care to be poor, with a complete breakdown in communication and failure to follow Department of Justice procedures. The coroner made recommendations to improve medication administration processes, ARMS documentation pro…
61y · Male·Complications of cutaneous burns
A 61-year-old man with severe chronic schizophrenia and extensive history of arson, suicide attempts and self-harm was admitted as a voluntary patient to a psychiatric inpatient unit and later made involuntary. Despite c…
0y · Female·premature delivery; extreme prematurity
A 19-week pregnant woman was admitted for pregnancy termination due to maternal psychological concerns. Labour was induced with misoprostol, expecting foetal death in utero or delivery of non-viable remains. Instead, a l…
24y · Male·Head injuries from blunt force trauma
…had adequate supervision been maintained. Systemic failures included poor documentation, lack of written procedures for prisoner associations, staff complacency, and failure to share critical incident information.
57y · Male·Multiple organ failure in consequence of peritonitis resulting from complication…
…nd nasogastric tube inserted on 18 July, death would likely have been prevented. Key lessons: specialist procedures require specific knowledge among ED staff; critical instructions must be clearly documented; failed clin…
35y · Male·exertional heat stroke
…ical systemic failures contributed to this preventable death: the deceased received no written emergency procedures, inadequate directions or maps, no satellite phone despite the remote location, insufficient water, and …
42y · Female·Hypoxic ischemic encephalopathy with antecedent cause being self-caused near mis…
Tania Pauline Lioulios, a 42-year-old psychologist, died from hypoxic ischemic encephalopathy following a self-inflicted hanging in a Corrective Services transport vehicle on 4 July 2008. She had presented to mental heal…
1y · Male·Hypoxic ischaemic encephalopathy
Dean Smith, a full-term neonate, was born severely asphyxiated after an induced labour managed at Central Gippsland Health Service. He died from hypoxic-ischaemic encephalopathy within 24 hours. The coroner found critica…
40y · Male·Head injury from assault
George Edgar Challis, a 40-year-old remand prisoner, died on 12 July 2006, eleven days after being assaulted by another inmate at Woodford Correctional Centre. He sustained a severe head injury from stomping to the head,…
39y · Male·Hypoxic ischaemic encephalopathy complicating acute upper airway obstruction by …
Bartosz Zgadzaj, a 39-year-old man with cerebral palsy and intellectual disability, died from hypoxic ischaemic encephalopathy secondary to acute airway obstruction from a food bolus. He choked while eating unsupervised …
24y · Male·Penetrating head injury due to industrial accident involving explosion and eject…
Troy Ronald Hooper, a 24-year-old labourer, died from a penetrating head injury caused by an exploding gas strut during removal of a prototype boat rack at his workplace. The incident occurred because the boat rack was p…
33y · Male·Multiple injuries consequent upon being struck by a truck
…taken him to his father's home or consulted their supervisor. Recommendations addressed police training, procedures for transporting non-arrested persons, and recorded interviews in custody deaths.
37y · Male·blunt force injuries to the head and chest from jumping off an 8.65 metre roof
Daniel Bleaney, 37, experienced acute psychosis with command hallucinations while at sea and attempted suicide by jumping overboard. He was rescued and admitted involuntarily to Cowdy Ward, an open psychiatric ward, foll…
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