76 results for “induction procedures”
21y · Male·Blunt force head injuries sustained in motor vehicle crash during police pursuit
…h-risk 'traffic red zones' on country highways, including mandatory notification and supervisor training procedures.
40y · Male·Unascertained
…e appropriate confined space training and accreditation, failure to notify South East Water using Form Q procedures, failure to provide training in the specific equipment and techniques required, and lack of understandin…
17y · Male·Cerebral ischaemia caused by hanging at Quamby Youth Detention Centre at approxi…
Mark Watson, a 17-year-old boy charged with assault, was detained at Quamby Youth Detention Centre. During his second remand in September 1996, after a failed hospital admission, he returned to the same unit where he had…
49y · Male·hanging
A 49-year-old man with severe schizoaffective disorder died by hanging in his prison cell while serving a 16-year sentence for murdering his three children. Despite a chronically high suicide risk and prior suicide attem…
43y · Male·Hanging
Mathew James Luttrell, a 43-year-old Aboriginal man with borderline personality disorder, chronic suicidal ideation and substance abuse, was admitted to Mildura Base Hospital following a suicide attempt on 11 November 20…
68y · Male·compression of the neck with contributing acute myocardial infarction due to cor…
…ting him in the infirmary as recommended; missing his psychiatric appointment due to inflexible lockdown procedures; inadequate medical assessment of chest pain with borderline ECG showing changes from previous baseline,…
67y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …
David Fensom, 67, underwent elective fundoplication for hiatus hernia and reflux on 21 September 2010. He developed severe right-sided abdominal pain post-operatively. A laparoscopy on 8 October misinterpreted findings a…
67y · Male·Intracranial haemorrhage complicating coronary artery bypass graft surgery follo…
…mination of whether the delay contributed to death. The coroner found suboptimal inter-hospital transfer procedures, lack of contemporaneous documentation of the referral discussion, and breach of the receiving hospital'…
39y · Female·smoke inhalation
Cheryl May Currie, 39, with complete paraplegia from a 1998 spinal cord injury, died from smoke inhalation in a bedroom fire on 12 June 2009. The fire was caused by smoking in bed. Investigation revealed critical systemi…
70y · Male·Cyanide Toxicity
Anthony Lansell Churches, a 70-year-old man with a history of substance use and criminal offences, died from cyanide toxicity after absconding from St Vincent's Hospital's Emergency Department. He had been placed on an i…
15y · Male·Cardiorespiratory arrest of unknown aetiology complicating hypoxic ischaemic enc…
Max McKenzie, a 15-year-old with asthma and food allergies, died from cardiorespiratory arrest complicating hypoxic ischaemic encephalopathy after severe refractory anaphylaxis. After eating apple crumble containing nuts…
77y · Male·sepsis due to retroperitoneal collection after biliary stent insertion on a back…
A 77-year-old Aboriginal man died from sepsis following a percutaneous transhepatic cholangiography (PTC) procedure that perforated his duodenum. Critical failures included: delayed diagnosis and treatment of peritonitis…
40y · Female·hypoxic encephalopathy and epilepsy with diffuse fibrillary astrocytoma within t…
Laura Parker, a 40-year-old woman with a long history of epilepsy, borderline personality disorder, and recent seizures, died at the Royal Adelaide Hospital on 16 March 2008 from hypoxic encephalopathy caused by cardiac …
28y · Female·compression of the neck and hanging
28-year-old Bridget Flack, a transgender woman experiencing complex mental health issues including depression, anxiety, borderline personality disorder and PTSD, died by suicide in December 2020 after becoming increasing…
19y · Male·gunshot wounds to chest and abdomen
…unity members, and planning for vulnerable individuals. Deaths in custody require improved investigative procedures, witness separation, and officer welfare. Recommendations address night patrols, youth diversion, access…
0y · Male·Head injuries (birth trauma) secondary to obstructed labour and fetal macrosomia…
…emented major reforms including enhanced consultant involvement, improved communication systems, and new procedures for managing impacted fetal heads.
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