Coronial

677 results for cardiac arrest

VIChospital2024-07-29

Finding into death of Shane Anthony Pappas

54y · Male·quetiapine toxicity in a man with ischaemic heart disease

Shane Pappas, a 54-year-old man with ischaemic heart disease, died from quetiapine toxicity after deliberately overdosing on multiple medications on 29 June 2021. He had experienced a recent relationship breakdown and pr…

psychiatryemergency medicinediagnosticcommunicationquetiapine
NSWhospital2021-11-19

Inquest into the death of Emiliana OBUSAN

1y · Female·unrecognised oesophageal intubation

A 19-month-old girl died from unrecognised oesophageal intubation during anaesthesia for finger laceration repair. The anaesthetic team failed to recognise multiple clinical indicators of tube misplacement: absence of pe…

anaesthesiaorthopaedic surgerydiagnosticcommunicationfentanyl
NSWhospital2021-10-12

Inquest into the death of Bruce HODGES

78y · Male·cardiorespiratory failure due to complications of tracheal stenosis

Bruce Hodges, a 78-year-old man with a 20-year-old tracheostomy following laryngeal cancer surgery, presented to hospital with progressive shortness of breath and tracheal stenosis. Over 48 hours of admission, his respir…

emergency medicineENT surgerydiagnosticsystemnebulised saline
QLDmental health2007-06-20

Liddell, Matthew John

28y · Male·hypoxic encephalopathy secondary to hanging

Matthew Liddell, a 28-year-old former Navy serviceman with severe post-traumatic stress disorder and depression following the 1998 HMAS Westralia fire, died by hanging in a psychiatric hospital. He had been admitted on 8…

psychiatryemergency medicinecitalopram
SAhospital2000-02-25

Coroner's Finding: STONEHOUSE Jarrod William (aka Scott)

23y · Male·aspiration of blood due to stab wound to trachea

23-year-old man with self-inflicted stab wound to neck presenting to emergency department while intoxicated and agitated. Ambulance noted 3cm laceration to midline trachea with minimal external bleeding. Registered nurse…

emergency medicinesurgerydiagnosticcommunicationalcohol
QLDPodcast2006-12-18

Boyce, Amanda Helen

13y · Female·Pneumonia, due to or as a consequence of Hypoxic Brain Damage, due to or as a co…

Amanda Helen Boyce, aged 13, drowned in a spa pool at a resort after her long hair became entrapped in the pump suction system. She was submerged for an estimated 10-20 minutes before being freed. Despite immediate CPR a…

emergency medicineintensive caresystemmaintenance
VICcommunity2020-11-19

Finding into death of Zachary Matthew Bryant

Unsurvivable traumatic injuries from blunt force impact with motor vehicle; pred…

On 20 January 2017, James Gargasoulas drove a stolen vehicle through Bourke Street Mall in Melbourne's CBD, striking 33 pedestrians and fatally injuring 6: Matthew Poh Chuan Si (33), Thalia Hakin (10), Yosuke Kanno (25),…

emergency medicinetrauma surgery
VICprison2013-07-19

Finding into death of Andrew Timothy Davies

39y · Male·Acute myocardial infarction arising from coronary artery atherosclerosis

Andrew Timothy Davies, a 39-year-old prisoner, presented with chest pain in August 2007. A 12-lead ECG was performed by Nurse Skrabl, a Division 2 registered nurse, showing abnormalities consistent with inferior myocardi…

cardiologyemergency medicinediagnosticcommunication
QLDhome2008-12-22

Plint, Hannah Isabella Alyson

2y · Female·Drowning in an above-ground swimming pool

Hannah Plint, a 2½-year-old, died from drowning after accessing an above-ground pool by dragging a chair to the gate and opening it unsupervised. Her mother was inside with a younger sibling. The pool fence and gate sepa…

emergency medicinepaediatricssystemdelay
VIChome2016-03-24

Finding into death of Caroline Emily Lovell

36y · Female·Global ischaemic injury following cardiorespiratory arrest in the immediate post…

Caroline Lovell, 36, died from postpartum haemorrhage following home birth of her second child. She had significant risk factors: prior PPH with first child and uterine fibroid, but these were not properly investigated b…

midwiferyobstetricsdiagnosticcommunicationsyntocin
VIChome2016-08-02

Finding into death of Stephen Liat Kai Lim

56y · Male·Benzalkonium chloride toxicity

Stephen Lim, aged 56, died from benzalkonium chloride toxicity after deliberately ingesting approximately 2.5 litres of Pine-O-Cleen disinfectant on 25 September 2010. His death occurred from acute lung injury due to asp…

emergency medicinetoxicologycommunicationsystembenzalkonium chloride
VIChome2021-08-04

Finding into death of NB

1y · Male·Global cerebral ischaemia in an infant with upper airway obstruction

NB, a 14-month-old with a tracheostomy requiring overnight nursing support in foster care, suffered a cardiac arrest on 17 December 2016 that resulted in severe hypoxic brain injury and death. The overnight nurse (M…

respiratory medicineintensive carediagnosticcommunication
NSWhospital2016-12-21

Inquest into the death Kyran DAY

0y · Male·Complications of hypoxic ischaemic encephalopathy secondary to recurrent episode…

…iving an R3 (not R1) response code contributed to deterioration during transfer. Kyran sustained multiple cardiac arrests before arriving at Sydney Children's Hospital with hypoxic ischaemic encephalopathy and ultimatel…

paediatricsemergency medicinediagnosticcommunication
WAhospital2013-05-01

Inquest into the Death of Squires, John Gregory

47y · Male·Pulmonary thromboembolism in association with deep vein thrombosis

…oea, and sweating. Despite rapid recognition by medical staff and appropriate investigations, he suffered cardiac arrest from massive pulmonary embolism with DVT before anticoagulation could be beneficial. Key preventab…

surgeryanaesthesiadiagnosticdelayheparin
VIChospital2014-09-12

Finding into death of Nola Margaret Moxon

77y · Female·Venlafaxine toxicity in a woman with severe renal impairment and depression

…weekend cover. Patient developed venlafaxine toxicity in context of severe renal impairment and went into cardiac arrest immediately prior to ECT. The coroner found the death was preventable through adequate medical rev…

psychiatrygeriatric medicinecommunicationsystemvenlafaxine
VIChospital2016-06-03

Finding into death of Ronak Satyajit Warty

10y · Male·complications of anaphylaxis

Ronak Satyajit Warty, a 10-year-old boy with known milk and nut allergies, died from anaphylaxis after ingesting a coconut drink that was mislabelled and contained undeclared dairy products. Despite his parents' diligenc…

emergency medicinepaediatricsdelaysystemadrenaline
SAcommunity2024-01-23

Coroner's Finding: Chua, Ardebby Oh

41y · Female·salt water drowning

Ms Ardebby Chua, a 41-year-old woman with no snorkelling experience, died from salt water drowning during a guided snorkelling tour near Blyth Island, South Australia. She aspirated water triggering laryngospasm and beca…

emergency medicinediving medicinesystemcommunication
ACThospital2024-09-11

Inquest Into The Death Of Baby X

0y · Male·Hypoxic-ischemic encephalopathy and massive subgaleal haemorrhage, both associat…

…d critically, delayed recognition of subgaleal haemorrhage in NICU. The haemorrhage went undetected until cardiac arrest at 15+ hours post-birth, despite visible scalp bruising from 27 minutes after birth. Delayed recog…

obstetricsneonatologydiagnosticcommunication
NSW2021-03-11

Inquest into the death of Nathan REYNOLDS

36y · Male·bronchial asthma

Nathan Reynolds, a 36-year-old Aboriginal man with severe asthma, died from bronchial asthma in prison on 1 September 2018. His death exposed critical failings in both immediate emergency response and chronic disease man…

respiratory medicineemergency medicinediagnosticsystemsalbutamol
NThome2025-12-05

Inquest into the death of Kumanjayi Fly

2y · Male·Hypoxic-ischaemic encephalopathy due to out of hospital cardiac arrest following…

A 2-year-old toddler died after falling into a septic tank in his family's public housing home in a remote Northern Territory community. The septic tank access cover was corroded and insecure due to systemic failures in …

systemdelay
130313234

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