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WAhospital2022-03-28

Inquest into the Death of Morgan John EDWARDS

31y · Male·Complications in association with intestinal volvulus

31-year-old Morgan Edwards with Smith-Magenis Syndrome, cerebral palsy and Crohn's disease was discharged from Fiona Stanley Hospital ED on 14 August 2018 without definitive diagnosis despite elevated respiration rate, u…

emergency medicinegastroenterologydiagnosticcommunication
NSWhospital2022-03-25

Inquest into the death of Anthony Barrett

54y · Male·Bowel ischaemia resulting from acute thrombosis of superior mesenteric artery an…

Anthony Barrett died from bowel ischaemia caused by acute thrombosis of his superior mesenteric artery and coeliac artery stents post-operatively. He had undergone left total knee replacement surgery at Fairfield Hospita…

orthopaedic surgeryvascular surgerycommunicationdiagnosticclopidogrel
TAShospital2022-03-21

Coroner's Finding: Mackey, Lois Winifred

83y · Female·decompensated right heart failure (cor pulmonale) immediately following mitral v…

An 83-year-old woman died from decompensated right heart failure (cor pulmonale) immediately following mitral valve replacement surgery. She had chronic pulmonary hypertension secondary to severe mitral regurgitation fro…

cardiothoracic surgerycardiologydiagnosticdelay
VIC2022-03-21

Finding into death of Nilofer Nezami

38y · Female·Unascertained

Nilofer Nezami, a 38-year-old Victorian resident, died on 7 January 2019 following cosmetic surgery in Iran. She underwent multiple procedures including eye, breast, arm and abdominal surgery. Post-operatively, she devel…

plastic and reconstructive surgeryanaesthesiasystemproceduralmorphine
VIChospital2022-03-15

Finding into death of Ann Leah Jones

87y · Female·Pulmonary artery rupture complicating pulmonary artery catheter insertion in a w…

Mrs Jones, an 87-year-old woman with severe ischaemic heart disease, died from pulmonary artery rupture during elective off-pump coronary artery bypass surgery. A Swan-Ganz pulmonary artery catheter (PAC) was inserted pr…

cardiothoracic surgeryanaesthesiaproceduralsystemfentanyl
TAShospital2022-03-09

Coroner's Finding: Salter, Lyndsay Kenneth

83y · Male·pulmonary fat embolism complicating interstitial lung disease

An 83-year-old experienced motorcyclist died from pulmonary fat embolism complicating interstitial lung disease following a compound fracture of the right tibia sustained in a motorcycle crash. Mr Salter lost concentrati…

emergency medicineorthopaedic surgery
VIChospital2022-02-28

Finding into death of H YR

77y · Female·Haemoperitoneum following cholecystectomy

A 77-year-old woman died from haemoperitoneum (intra-abdominal bleeding) three days after elective laparoscopic cholecystectomy. Bleeding from the left inferior epigastric artery was a recognised surgical complication bu…

general surgeryintensive carediagnosticdelaywarfarin
VIChospital2022-01-20

Finding into death of Ann-Maree Manno

57y · Female·Pulmonary thromboembolism

Ann-Maree Manno, 57, died from pulmonary thromboembolism 8 days after laparoscopic gastric band surgery. She had significant risk factors: obesity (BMI 37.9), history of unprovoked DVT in 2007 and 2016, and recent surger…

bariatric surgeryanaesthesiacommunicationsystemheparin
VIChospital2022-01-07

Finding into death of CDK

71y · Female·Complications post aortic endarterectomy

A 71-year-old woman died from complications following elective aortic endarterectomy for leg claudication. Post-operatively, she developed acute bilateral lower limb ischaemia with absent pulses, pale/mottled skin, and s…

vascular surgeryintensive carediagnosticdelayenoxaparin
WAhospital2022-01-06

Inquest into the Death of Louisa Betty RYAN

89y · Female·aspiration pneumonia with respiratory failure complicating major depression with…

Louisa Betty Ryan, 89 years old with major depression with catatonia, atrial fibrillation, pulmonary oedema, diabetes and Parkinsonism, died from aspiration pneumonia with respiratory failure following electroconvulsive …

psychiatryanaesthesia
VIC2021-12-17

Finding into death of KW

4y · Unknown·Drowning

A 4-year-old boy drowned in a resort pool during a family birthday party on 13 December 2020. Despite wearing a buoyancy vest initially, he removed it to use water slides more freely. While approximately 8 adults were pr…

emergency medicineanaesthesiasystemdelay
NSWhospital2021-12-02

Inquest into the death of Joshua Szczudlo

33y · Male·Fatal cardiac arrhythmia, secondary to acute kidney injury

Joshua Szczudlo, a 33-year-old man with morbid obesity (estimated weight 195kg), underwent shoulder fracture repair surgery on 17 March 2016 at Liverpool Hospital. He died 38 hours post-operatively from a fatal cardiac a…

orthopaedic surgeryanaesthesiasystemcommunicationmorphine
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
VIChospital2021-11-17

Finding into death of H J

76y · Female·Undetermined (natural causes)

HJ, a 76-year-old woman with chronic psychotic disorder and paranoid delusions, presented with abdominal pain, vomiting, and small bowel obstruction. Imaging revealed bilateral adnexal masses. Due to her lack of insight …

general surgerypsychiatryaugmentin df
VICcommunity2021-11-12

Finding into death of Michael Anderson

36y · Male·Cardiorespiratory arrest complicating propofol administration for endodontic pro…

Michael Anderson, a 36-year-old obese man (BMI 38.5), suffered cardiorespiratory arrest during a root canal procedure under conscious sedation with propofol administered by Dr S. in a dental office setting. He had undiag…

anaesthesiadentistrycommunicationdocumentationpropofol
VIChospital2021-11-08

Finding into death of Baby MNL

0y · Male·Hypoxic ischaemic encephalopathy complicating peri partum asphyxia

A term neonate died at 3 days of age from hypoxic ischaemic encephalopathy due to perinatal asphyxia. The mother presented in early labour, was initially discharged, then readmitted when labour progressed. Labour progres…

obstetricsneonatologysystemcommunicationterbutaline
QLDhospital2021-11-01

Masoumali, Omid

24y · Male·Multiple organ failure due to or as a consequence of severe thermal burns

Omid Masoumali, a 24-year-old Iranian refugee detained on Nauru under Australian offshore processing arrangements, suffered severe thermal burns (>50% TBSA) on 27 April 2016 after self-immolating at the Nibok settlement.…

plastic and reconstructive surgeryintensive carecommunicationsystem
VIChospital2021-10-26

Finding into death of John Francis Flynn

69y · Male·Hypoxic ischaemic brain injury secondary to right facial artery pseudoaneurysm r…

69-year-old male with tonsillar squamous cell carcinoma presenting with throat pain and trismus 12 days after completing chemoradiotherapy. On presentation to emergency department with bleeding, airway risk was under-rec…

emergency medicineENT surgerydiagnosticcommunicationparacetamol/codeine
VIChospital2021-10-25

Finding into death of MR XH

46y · Male·Hypoxic ischaemic brain injury complicating a cardiac arrest during anaesthetic …

A 46-year-old male underwent elective inguinal hernia repair at a private hospital. During anaesthetic induction, he experienced cardiac arrest. The endotracheal tube (ETT) was visualized passing through the vocal cords,…

anaesthesiaintensive carediagnosticproceduralfentanyl
WAmental health2021-10-22

Inquest into the Death of Russell David BROCKLISS

38y · Male·acute cardiac arrhythmia in a man with cardiomegaly, focal coronary atherosclero…

Russell Brockliss, a 38-year-old Aboriginal man with severe treatment-resistant schizoaffective disorder and significant cardiovascular risk factors (obesity, smoking, focal coronary atherosclerosis), died from acute car…

psychiatryemergency medicinedelaysystemrisperidone depot
156723

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