303 results for “ventilation failure”
56y · Female·multi-organ failure due to anorexia nervosa
A 56-year-old woman with a long history of anorexia nervosa and a BMI of 10.3 died from multi-organ failure after admission to hospital. She was found on her bedroom floor, dehydrated and malnourished, and was inv…
0y · Male·Sudden Infant Death Syndrome (SIDS) Category II
…ecked only every 20-30 minutes despite policy requiring 10-minute checks; the room was hot with limited ventilation and door closed; the educator was caring for up to six children under school age, exceeding approved ra…
67y · Female·choking and ischaemic heart disease
…ain bronchus. Staff responded promptly to her gurgling sounds and attempted resuscitation with bag-mask ventilation, but she was not intubated given her DNR status and poor prognosis. The coroner found her care was appr…
53y · Male·Complications of burns sustained in a blast
A 53-year-old qualified boiler maker died from complications of severe burns sustained in a gas explosion. While attempting to remove a refrigeration compressor from a hotel cellar with an unqualified colleague, they cut…
57y · Female·Complications of muscular dystrophy
…asonable and appropriate. The death was not preventable; it resulted from the combined effects of cardiac failure, infection, and the progressive nature of her neuromuscular condition. The coroner found no material fail…
63y · Male·Aspiration pneumonia in a man with trisomy 21, Alzheimer's dementia and other me…
…o hospital on 8 September 2024 with hypoxia and tachypnoea, was started on antibiotics and non-invasive ventilation, but his condition deteriorated over several days leading to a transition to end-of-life care. The coro…
5y · Male·aspiration pneumonia with terminal palliative care, in a male child with complex…
… medical needs including unsafe swallowing, recurrent respiratory infections, and required non-invasive ventilation support. During his final admission, a Do Not Resuscitate order was appropriately established after dis…
48y · Female·Combined effects of cardiac hypertrophy, chronic obstructive pulmonary disease a…
KD, a 48-year-old woman with chronic schizo-affective disorder, end-stage renal failure, COPD, cardiac hypertrophy and obesity, died from combined natural causes while under assessment order in…
8y · Male·Carbon monoxide poisoning
…at CO poisoning from domestic appliances is preventable through regular professional servicing, testing ventilation systems for safety, and avoiding retrofit exhaust fans without gas fitter assessment. Early warning sig…
26y · Male·Cardiomegaly in a man with Prader-Willi syndrome
…ext of Prader-Willi syndrome and severe obesity. He had a complex medical history including obesity hypoventilation syndrome, type 2 respiratory failure requiring BiPAP support, and recent presentations to ED with chest…
41y · Male·multi-organ failure due to severe lactic acidosis due to metformin toxicity
…s admitted to ICU where dialysis was commenced. Despite appropriate management including intubation and ventilation, severe lactic acidosis developed consistent with lethal metformin concentrations, leading to multi-org…
64y · Female·Haemorrhage into atheromatous plaque, due to coronary atherosclerosis
…c event on 5 May 2008 requiring emergency pacemaker insertion. After three weeks in ICU with mechanical ventilation, she was transferred to a medical ward where an equipment malfunction (fractured in-line suction system…
Unknown·Ms Fensom: influenza A (H1N1 2009, pandemic swine flu) with myocarditis causing …
…have been prevented. After admission on 10 August with pneumonia, he required intubation and mechanical ventilation by 11 August evening (24 hours earlier than it occurred), with prompt retrieval to tertiary ICU. Confus…
30y · Male·compression of the neck consistent with hanging
… with his partner about relationship breakdown and infidelity concerns, Mr Smith hanged himself using a ventilation grille as the hanging point. Prisoners knew of his distressed state but did not report it. Key lessons …
Male·Asphyxia, caused by the inhalation of severely oxygen-depleted air
… sealed hatch door to a GOAF (worked-out coal area) containing severely oxygen-depleted air. The critical failure was the mine's grossly deficient record-keeping system: job cards contained outdated sensor location info…
87y · Male·infective exacerbation of chronic obstructive lung disease
…quently revealed emphysema and signs of infection. He deteriorated despite antibiotics and non-invasive ventilation, ultimately dying from infective exacerbation of chronic obstructive pulmonary disease. The coroner fou…
66y · Male·hepatorenal failure and biliary sepsis complicating common bile duct obstruction
A 66-year-old man incarcerated in Port Lincoln Prison died from hepatorenal failure and biliary sepsis complicating common bile duct obstruction. He presented with progressive jaundice, dar…
Male·carbon monoxide intoxication due to inhalation of exhaust from a petrol generato…
Gregory John Burling died from carbon monoxide intoxication in the cabin of a boat at Gepp Parade Marina, Tasmania. A portable petrol generator in an enclosed machinery space had a poorly constructed exhaust system with …
33y · Male·Multi-organ failure due to sepsis on a background of severe ischaemic cardiomyop…
Wayne Robert McInnes Thompson, aged 33, died from multi-organ failure due to sepsis complicated by severe ischaemic cardiomyopathy. He had a complex medical history including …
5y · Female·disseminated candidiasis secondary to protein-energy malnutrition
…edical attention until December 16, when she presented in septic shock with hepatic dysfunction and renal failure. Transfer to Royal Children's Hospital for intensive care with mechanical ventilation, hemofiltration, an…
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