Coronial

59 results for oxygen administration

SAhospital2013-02-08

Coroner's Finding: FENSOM Angela Catherine and TAANKINK Johaanes Andrew

Unknown·Ms Fensom: influenza A (H1N1 2009, pandemic swine flu) with myocarditis causing …

Two deaths from H1N1 influenza in 2009. Ms Fensom (41) died from myocarditis complicating swine flu after inadequate recognition and management of persistent hypotension at Millicent Hospital. Her condition required esca…

emergency medicinegeneral practicediagnosticcommunicationoseltamivir
VIChospital2014-08-12

Finding into death of Baby Paula Victoria OShea

0y · Female·Intra-uterine hypoxia

Baby Paula O'Shea was born at Sandringham Hospital at term following spontaneous labour. Labour was augmented with IV Syntocinon after ARM. Cardiotocography (CTG) monitoring was difficult to interpret due to poor detecti…

obstetricsmidwiferydiagnosticoxytocin
SAhospital2006-10-30

Coroner's Finding: GORDON Sally Anne

20y · Female·Cerebral anoxia consequent upon a severe acute asthmatic event

…th acute severe asthma unresponsive to initial treatment. After appropriate emergency management including oxygen, adrenaline and hydrocortisone, she was transferred to the High Dependency Unit where intubation became ne…

emergency medicineanaesthesiamedicationproceduralsalbutamol
WAcommunityPodcast2016-08-22

Inquest into the Death of Ewan Louis WILLIAMSON

14y · Male·severe heatstroke complicating a recent viral illness with focal myocarditis

A 14-year-old boy from Scotland died of severe heatstroke with myocarditis while hiking in extreme heat (40°C+) at Cape Range National Park. He had recently recovered from a viral illness. His father made navigation erro…

emergency medicineparamedicinecommunicationdelay
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
WAhospital2005-09

Inquest into the Death of Maria Donatelli

72y · Female·Peritonitis due to perforated diverticulum in transverse colon

Maria Donatelli, a 72-year-old woman with cardiac and renal disease, presented to Peel Health Campus with abdominal pain and vomiting. She was initially managed conservatively with a provisional diagnosis of pancreatitis…

general surgeryemergency medicinediagnosticcommunicationtramadol
QLDhospital2017-04-04

Coolwell, Bradley Karl

39y · Male·respiratory failure and cardiac arrest

…, where blood gas analysis revealed critical hypoxemia (pO2 48mmHg, PaCO2 100mmHg) following midazolam administration. Despite these serious findings suggesting respiratory compromise, he was transferred to the mental he…

emergency medicinepsychiatrydiagnosticcommunicationmidazolam
WAcommunity2010-04-15

Inquest into the Death of Lynch

20y · Female·food-induced anaphylaxis, likely to peanut allergen

…hone guidance from Dr D. at Exmouth Hospital 150km away. Despite appropriate emergency treatment including oxygen, nebulised and intramuscular adrenaline, intravenous hydrocortisone, and an attempted cricothyroidotomy, K…

emergency medicinegeneral practicedelaydiagnosticadrenaline
WA

Inquest into the Death of Jarrod Arthur HAMPTON

22y · Male·drowning secondary to incapacitation from air embolism

A 22-year-old skilled and experienced pearl shell drift diver with over 600 logged dives died from drowning secondary to air embolism and cerebral arterial gas embolism while diving for Paspaley Pearling Company off Broo…

diving medicineoccupational and environmental healthsystemdelay
SAcommunity2010-04-01

Coroner's Finding: HALLORAN James Gordon

52y · Male·hypoxic-ischaemic encephalopathy due to cardiac arrest due to unknown aetiology

James Halloran, age 52, collapsed during chiropractic treatment and suffered cardiac arrest of unknown aetiology. He remained unconscious despite resuscitation and died from hypoxic-ischaemic encephalopathy. Initially su…

emergency medicineintensive caredelaycommunication
NSWhospital2018-12-04

Inquest into the death of June Nutter

58y · Female·lymphangitic carcinomatosis leading to hypoxaemic respiratory failure and cardia…

…copy and colonoscopy at a private hospital to investigate suspected gastric pathology. She had hypoxaemia (oxygen saturations 90% on room air) preoperatively. Though the procedure was reasonable, she was admitted to HDU …

anaesthesiagastroenterologymedicationproceduralfentanyl
SAhospital2011-06-22

Coroner's Finding: TRENGROVE Ian

81y · Male·Retropubic and retroperitoneal haemorrhage complicating pelvic fractures with co…

An 81-year-old man died from retropubic and retroperitoneal haemorrhage complicating pelvic fractures sustained in a fall at church. He was on warfarin for atrial fibrillation with an excessive INR of 4.6 at the time of …

emergency medicinegeneral medicinediagnosticcommunicationwarfarin
NSW2014-06-06

Inquest into the death of Mandaswamy SHANKARANARAYANA

40y · Male·Suicide by hanging while on remand in custody

A 40-year-old man remanded in custody on homicide charges died by hanging in his prison cell 7 months after arrest. He had been assessed as at risk of self-harm initially and placed under 'green card' (two-person cell) s…

psychiatrypsychologysystemcommunication
SAaged care2018-09-28

Coroner's Finding: ROLLBUSCH Graham

70y · Male·combined effects of severe pulmonary emphysema, ischaemic heart disease and rece…

A 70-year-old man with severe COPD, dementia and a history of sexually inappropriate behaviour died following an assault by another resident with dementia. The coroner found institutional failures in care standards inclu…

geriatric medicinepsychiatrydiagnosticcommunicationolanzapine
QLD2011-11-24

Choi, Seongeun; Park, Sang Won

Unknown·Ms Choi: hypoxic brain damage due to drowning/immersion due to rafting accident;…

Two language students died following a white water rafting incident on the Tully River. A collision between rafts diverted one raft into a hazardous channel, causing it to strike Sieve Rock and flip. Both occupants becam…

emergency medicineintensive caresystemcommunication
NSWaged care2025-01-24

Inquest into the deaths at Newmarch House

Unknown·COVID-19 infection with various comorbidities as contributing factors

This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…

geriatric medicineinfectious diseasessystemdiagnosticmorphine
VIChospital2008-08-15

Finding into death of William Grant Keays

Male·Hypoxic brain injury arising from intra-uterine asphyxia (causative factors unas…

William Keays was a neonate born at 37 weeks via emergency caesarean section for fetal distress during labour induction with Syntocinon. He was stillborn with Apgar scores of 0/0/1, requiring 12 minutes of resuscitation …

obstetricsneonatologycommunicationdelayoxytocin
SAhospital2017-04-07

Coroner's Finding: MAYELL Edward John

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

An 83-year-old man died from pneumonia and respiratory distress caused by Legionella bacterium. He presented with abdominal symptoms and was initially misdiagnosed as having aspiration pneumonia rather than community-acq…

emergency medicinegeneral practicediagnosticmedicationceftriaxone
VIC2023-06-22

Finding into death of Cherie Virginia Pearl Guest

61y · Female·Diffuse alveolar damage in a woman with restrictive lung disease following catar…

… surgery at a private day surgery centre on 13 August 2018. She was unable to lie flat and became hypoxic (oxygen 60%) during the first part of the procedure. Despite this decompensation, the second part proceeded, requi…

ophthalmologyanaesthesiadiagnosticcommunicationlidocaine

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