Coronial

148 results for ICU admission

VIChospital2023-10-02

Finding into death of Trevor James Bayldon

55y · Male·Bronchopneumonia in a man with functional decline and trisomy 21

…l support. After discussion with carers acknowledging his poor functional baseline and progressive frailty, ICU admission was deemed not in his best interests. He received palliative care and died the following day. The…

emergency medicinepalliative care
VIChospital2025-04-01

Finding into death of ZSQ

81y · Male·Community acquired pneumonia in a man with acute on chronic renal failure

…ronic renal failure. He presented to hospital on 25 April 2023 with respiratory failure and was admitted to ICU requiring intubation and multi-organ support. He was extubated briefly but required re-intubation and died …

intensive carerespiratory medicinediagnosticdelayadrenaline
VIChospital2024-11-11

Finding into death of Luke McCormack

48y · Male·Aspiration pneumonia

…lised until 9 January when emergency services transported him. He deteriorated in hospital, was admitted to ICU, and died on 18 January. The coroner found no clinical management failures by either the support provider o…

emergency medicineintensive careantibiotics
NSWcommunity2016-01-29

Jimmy JAMES - Findings

44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)

…ommunicated to or acted upon by treating physicians. Inadequate fluid resuscitation, failure to escalate to ICU promptly, incomplete antibiotic therapy, and poor clinical handover allowed the patient to deteriorate to c…

emergency medicineintensive carediagnosticmedicationceftriaxone
NSWhospital2022-04-05

Inquest into the death of Ronald TURNER

81y · Male·Consequences of bowel obstruction

…. However, unexpected vomiting on 25 January led to aspiration pneumonia and respiratory distress requiring ICU admission. The coroner found no clinical indication for earlier escalation, that care was appropriate throu…

colorectal surgerygeriatric medicine
VIChospital2014-12-16

Finding into death of Michael Justin Nicoll

36y · Male·Multiorgan failure complicating Streptococcus pyogenes septicaemia

…o days later in septic shock with Streptococcus pyogenes septicaemia and multi-organ failure, dying despite ICU care. The coroner found admission on initial presentation, with further investigation and IV antibiotics, w…

emergency medicineintensive carediagnosticsystemondansetron
VIChospital2025-08-20

Finding into death of Christine Klofa

47y · Female·Mycoplasma pneumonia secondary to rhinovirus infection

…X-ray confirmed pneumonia and she was referred to the ED. She deteriorated rapidly requiring intubation and ICU admission at Frankston Hospital. Given her previously expressed wish to avoid prolonged mechanical ventilat…

general practiceemergency medicineamoxicillin
VIChospital2015-10-14

Finding into death of Marc Phillip Vella

39y · Male·Infective endocarditis, with intravenous drug use as a contributing factor

…ified pneumonia, septicaemia, and possible bacterial endocarditis. His mental health deteriorated during admission, necessitating a Mental Health Act order variation to enable medical treatment. Despite appropriate clin…

emergency medicinegeneral medicinemethamphetamine
VIChospital2023-03-10

Finding into death of Armin Andrew Schaefer

63y · Male·Hypoxic ischaemic brain injury and pneumonia complicating cardiac arrest in a ma…

…d in ED despite high-risk medication exposure; lack of communication to psychiatric unit staff of his prior ICU admission for medication-induced oversedation; inadequate observations (vital signs not recorded) after pla…

psychiatryemergency medicinediagnosticcommunicationdiazepam
ACThospital2026-05-12

Inquest into the death of Mr Deleman

69y · Male·peritonitis due to perforated bowel

… Treatment Order on 15 April 2024. Despite receiving appropriate psychiatric and medical care during his admission, he developed peritonitis secondary to large bowel perforation, complicated by Clostridium bacteraemia a…

emergency medicinegastroenterologypaliperidone
VIChospital2024-08-14

Finding into death of Gayle Dianne Ireland

63y · Female·Sepsis with multiorgan failure in the setting of limb cellulitis complicating a …

…e to see her GP in one week. She returned on 24 January 2024 hypoxic and hypotensive with sepsis, requiring ICU admission. Despite treatment with antibiotics and supportive care, she deteriorated from sepsis with multio…

emergency medicineintensive carediagnosticdelayceftriaxone
VIChospital2024-11-29

Finding into death of Michael King

59y · Male·Aspiration pneumonia secondary to recurrent anal squamous cell carcinoma with su…

…argy and suspected urinary tract infection, aspiration pneumonia and small bowel obstruction. After initial ICU admission and improvement, he was transferred to Peter MacCallum Cancer Centre for ongoing management. He d…

oncologyintensive care
VICmental health2026-04-27

Finding into death of GM

Female·Fulminant hepatic failure due to paracetamol toxicity

…l service station. She presented with fulminant hepatic failure and despite transfer to the Austin Hospital ICU for potential liver transplantation, died on 22 August 2023. The coronial review found no specific clinical…

psychiatryintensive careparacetamol
VIChospital2012-08-15

Finding into death of Vanessa Jenner

38y · Female·Septicaemia, urosepsis, and Lennox Gastaut syndrome

…a urinary tract infection and infected haematoma requiring transfusions. Deterioration on 8 February led to ICU admission, but after discussion with family on 9 February, active treatment (intubation, drainage, aggressi…

intensive caregeneral medicine
WAhospital2019-07-30

Inquest into the Death of Child KT (Name Subject to Suppression Order)

7y · Male·cardiorespiratory failure in a child with cerebral palsy and epilepsy, with acut…

…e), age 7, died of cardiorespiratory failure from cerebral palsy and epilepsy after a prolonged hospital admission. He had complex medical needs including chronic respiratory disease, requiring PEG feeding and multiple …

paediatricsintensive caresystemmorphine
NSWhospital2025-11-17

Inquest into the death of Brooke Tiddy

32y · Female·Cardiac arrest due to hypoxia caused by dynamic hyperinflation arising from comp…

…plex patients—Dr D.'s bedside exam missed the condition because he never read "Sponastrime Dysplasia" on admission forms; (3) Surgeon-anaesthetist communication before admission was absent despite being standard for com…

bariatric surgeryanaesthesiadiagnosticcommunicationsevoflurane
QLDhospital2014-12-09

Baby A - Non-inquest findings

Male·Hypoxic-ischaemic encephalopathy due to meconium aspiration syndrome

…ic encephalopathy due to meconium aspiration. Critical failures in fetal monitoring were identified: the admission CTG was abnormal but not recognised as such by the midwife; continuous CTG monitoring was not performed …

obstetricsmidwiferydiagnosticprocedurallabetalol
VICmental health2015-08-06

Finding into death of WJ

39y · Female·Hypoxic brain injury secondary to hanging

… psychiatric unit after presenting to ED with suicidal ideation. Despite documented suicidal thinking at admission, she was assessed as low-risk and placed in the Low Dependency Unit without routine removal of potential…

psychiatryintensive carediagnosticcommunicationduloxetine
NThome2008-06-03

Inquest into the death of Lee Shaun Wurramarrba

15y · Male·bronchopneumonia secondary to chronic chest dysmorphology caused by congenital b…

…genital condition predisposing him to chest infections. He had nearly died from pneumonia in 2005 requiring ICU admission. Care coordination involved multiple agencies and specialist doctors. The coroner commended the K…

paediatricsneurologylamotrigine
SAhospital2011-06-22

Coroner's Finding: TRENGROVE Ian

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

… excessive INR of 4.6 at the time of injury. Critical failures included: (1) no INR testing on emergency admission despite warfarin use—a routine test that would have revealed over-anticoagulation; (2) failure to recogn…

emergency medicinegeneral medicinediagnosticcommunicationwarfarin
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