677 results for “cardiac arrest”
57y · Female·multi-organ failure due to sepsis caused by streptococcus pneumoniae infection
… ED and ward at 3:30pm lacked specificity, resulting in failure to escalate or initiate antibiotics until cardiac arrest was imminent. Earlier antibiotic therapy (by midday-3:30pm) would likely have saved her life.
25y · Male·coronary thrombosis resulting from coronary atherosclerosis
A 25-year-old Aboriginal man with undiagnosed coronary artery disease collapsed and died one hour after a consultation at an Aboriginal health clinic. The coroner found the medical examination by Dr M. was inadequate and…
60y · Female·Multiple organ failure following hemorrhage from penetration of the femoral arte…
…ding pain relief and antibiotics. The deceased collapsed on 27 October and was transferred to hospital in cardiac arrest, but her condition was not recoverable. The coroner found this death was preventable: referral to …
40y · Male·Unascertained; opioid withdrawal-related seizure or cardiac arrhythmia could not…
…eroin addiction, died in Melbourne Assessment Prison on 18 February 2019 from unascertained causes. He was arrested on 12 February after erratic driving, underwent police restraint with baton strikes and OC spray, then w…
2y · Male·drowning (immersion)
A 2-year-old boy, Kaled Kanj, drowned in a leisure pool at a public aquatic centre while attending with his mother and three siblings. His mother was supervising four children while also holding a 9-month-old infant, mak…
1y · Male·Hypoxic-ischaemic encephalopathy and multisystem failure in the setting of extre…
Baby B was born by emergency breech extraction in an ambulance after obstructed labour, sustaining severe hypoxic-ischaemic injury. The death was multifactorial. The mother had limited antenatal care despite known metham…
5y · Male·Septic shock due to Influenza A infection and bacterial co-infection with Staphy…
…ned before discharge despite tachycardia (149 bpm) at 7:21 pm. He re-presented moribund 12 hours later in cardiac arrest. Clinical lessons include: sepsis was not actively considered in the differential; the Queensland …
60y · Male·Global cerebral ischaemia post cardiac arrest in the setting of neck compression
Joseph Pezzimenti, a 60-year-old involuntary psychiatric patient, died from cerebral ischaemia following hanging by a tracksuit cord in a Low Dependency Unit bathroom. Key clinical lessons include: communication difficul…
69y · Female·Asthma
…cally ill by morning, deteriorated further during transfer to ICU at another hospital, and suffered fatal cardiac arrest. The coroner found the hospital system responsible, not individual clinicians, and made recommenda…
30y · Female·Hypoxic brain injury due to mixed drug toxicity (vecuronium and atropine self-in…
Candice Mackenzie Wallace-Mohlmann, a 30-year-old woman with chronic schizophrenia and substance abuse history, died from hypoxic brain injury caused by self-injection of vecuronium and atropine obtained from a hospital …
46y · Female·Multiple injuries sustained in collision between semi-trailer and train; tension…
On 5 June 2007, a semi-trailer collided with a V/Line passenger train at Kerang level crossing in Victoria, killing 11 train passengers immediately and one more (Harold Long) during transfer. The driver (Mr Scholl) faile…
2y · Male·Hypoxic brain injury following immersion (drowning)
Lachlan Mitchell, a 2-year-old with global developmental delay and hypermobility, drowned in a swimming pool at a family day care home on 9 November 2015, suffering fatal hypoxic brain injury. While swimming pools were n…
0y · Unknown·unascertained
A 10-day-old neonate born at 36 weeks gestation presented to hospital with signs of sepsis including hypothermia, lethargy, poor feeding, and jaundice. Critical failures in recognition and triage occurred: the infant was…
1y · Female·Gastrointestinal haemorrhage due to aorto-oesophageal fistula caused by lodged b…
Isabella Rees, aged 14 months, presented to Sunshine Hospital ED four times over 19 days with fever, vomiting and later haematochezia. A button battery lodged in her oesophagus caused progressive caustic injury leading t…
47y · Male·Complications of acute agitation in the setting of a prolonged struggle in an ac…
Ricky Broughton, a 47-year-old man with chronic treatment-resistant schizophrenia, died during police restraint while being transferred for involuntary psychiatric assessment. After moving from Geelong to Ballarat in Feb…
61y · Female·Multiple drug (tapentadol, morphine, diazepam, citalopram) intoxication
Margaret Cahill, a 61-year-old nurse assistant, died from multiple drug intoxication after a GP administered 60mg intramuscular morphine without knowing she had consumed tapentadol 1-2 hours earlier. The coroner identifi…
Unknown·Multiple: Olanzapine toxicity, pulmonary thromboembolism, asphyxiation on food, …
…nts had schizophrenia on multiple antipsychotic medications and severe, untreated physical comorbidities (cardiac disease, COPD, obesity). The coroner found preventable clinical failures: (1) antipsychotic polypharmacy …
44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)
…promptly, incomplete antibiotic therapy, and poor clinical handover allowed the patient to deteriorate to cardiac arrest. Expert opinion suggested that appropriate aggressive resuscitation, fluid loading, blood cultures…
34y · Male·Hypoxic/ischaemic brain injury following resuscitated cardiac arrest and hanging
Stuart Brant Garten, a 34-year-old man with complex psychiatric diagnoses including borderline personality disorder, post-traumatic stress disorder, and schizophrenia, died by hanging in the courtyard of a secure extende…
59y · Male·Ruptured atherosclerotic abdominal aortic aneurysm (operated)
…ght on 22-23 April. Emergency surgery on 23 April revealed rupture and perioperative complications led to cardiac arrest and death. The coroner found the surgical delays suboptimal; had surgery occurred promptly on admi…
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