329 results for “delivery”
17y · Female·Gamma hydroxybutyrate (GHB) toxicity
…deterioration, and consciousness assessment protocols. Staff handover processes were inadequate, training delivery was insufficient, and policy updates following JZA's return were not effectively communicated. While the …
0y · Female·Birth asphyxia due to tight umbilical cord around neck with meconium aspiration
…roximately 30 minutes without examining the patient or commencing immediate intervention. Early caesarean delivery at approximately 11:30pm likely would have saved the baby. The coroner found substandard care by both nur…
58y · Female·Pentobarbitone toxicity
A 58-year-old dog groomer died by suicide at a veterinary clinic by self-injecting with pentobarbitone (Lethabarb), an animal euthanasia drug. The coroner found that while the clinic's storage (unlocked cupboard) complie…
26y · Female·Pulmonary embolism as a consequence of dislodged deep vein thrombosis
Naomi Smith, aged 26, died from pulmonary embolism caused by dislodged deep vein thrombosis while in ICU at Royal Darwin Hospital. She had complex mental health needs (BPD, PTSD, depression) and morbid obesity. The criti…
0y · Male·Intrapartum hypoxia due to true knot in umbilical cord with cord wrapped three t…
…econd stage, the baby's heart rate declined from 122 to 70 bpm, but this was not considered concerning as delivery was thought imminent. The midwives performed their duties appropriately given the absence of prior diagno…
31y · Male·Multiple blunt traumatic injuries sustained from being run over by a truck
… lay across the centre of Lampton Avenue in poorly lit conditions. A taxi driver avoided him, but a bread delivery truck struck him approximately two minutes later. The coroner found no clinical failures or preventable e…
62y · Male·Cerebral ischaemic injury due to hanging
Gerard Helliar, a 62-year-old man with severe bipolar affective disorder, died from hanging in Frankston Hospital psychiatric ward on 16 November 2012 after an involuntary admission for treatment-resistant depression wit…
64y · Male·Multiple injuries from being struck by motor vehicle(s) in a second crash on the…
…ntions are relevant to this finding, as the case involves a fatal traffic accident rather than healthcare delivery.
50y · Male·hepatic encephalopathy secondary to liver cirrhosis with background of hepatitis…
…rium. Despite appropriate medical management including fluid drainage, PICC line insertion for medication delivery, antibiotic treatment for peritonitis, and endoscopic assessment revealing oesophageal varices, his condi…
95y · Male·multi-organ failure due to sepsis and general inanition on a background of advan…
…infections requires appropriate assessment and restraint of aggressive behaviour to enable necessary care delivery.
0y · Male·Global cerebral hypoxic injury and perinatal asphyxia secondary to uterine ruptu…
…The death was preventable. His mother, Ms Thurgood, had two prior caesarean sections and refused hospital delivery despite clear medical advice from obstetricians about the 2% rupture risk and need for continuous CTG mon…
37y · Male·Carbon monoxide poisoning
Benjamin Gleeson, a 37-year-old man, died from carbon monoxide poisoning by exhaust inhalation. He had a history of methamphetamine use, depression with suicidal ideation, and was a perpetrator of family violence. Despit…
69y · Male·disseminated urothelial carcinoma of the bladder (palliated), bilateral lung ade…
… medical treatment was provided during incarceration. There were no identified deficiencies in healthcare delivery or preventable factors contributing to his death.
0y · Male·Amniotic fluid aspiration (severe); with contribution from thin umbilical cord a…
Archer Langley died at age 1 hour from severe amniotic fluid aspiration following delivery by emergency caesarean section for obstructed labour. His mother's labour was prolonged and difficult, bu…
68y · Male·Ischaemic heart disease (operated); severe native coronary artery atheroma with …
Brian John Schulze, aged 68, died of ischaemic heart disease (operated) while subject to a Mental Health Act inpatient treatment order at Flinders Medical Centre. He presented with falls, confusion, and agitation followi…
36y · Female·multiple blunt force injuries sustained after intentional self-infliction by fal…
…pulsive disorder (OCD) following her daughter's birth in July 2020, characterised by rumination about her delivery experience at Nepean Hospital. Multiple care gaps emerged: inadequate antenatal mental health screening; …
11y · Male·Sepsis
An 11-week-old premature infant presented to the ED with fever, lethargy and poor feeding. Despite initial suspicion of sepsis at 1:15pm, antibiotics were not administered until 4pm—a three-hour delay. Key failures inclu…
Unknown·Ms Fensom: influenza A (H1N1 2009, pandemic swine flu) with myocarditis causing …
Two deaths from H1N1 influenza in 2009. Ms Fensom (41) died from myocarditis complicating swine flu after inadequate recognition and management of persistent hypotension at Millicent Hospital. Her condition required esca…
36y · Male·Blunt head injury
Chad Lynch, a 36-year-old truck driver, died from blunt head injury after a hydraulic hoist lug failed while he was on a livestock unloading ramp at an abattoir. The ramp lug was poorly designed, inadequately maintained,…
69y · Male·advanced cholangiocarcinoma
…ish proficiency, and more consistent use of interpreters would have improved communication and healthcare delivery. Justice Health acknowledged this as a learning point and reinforced policy requirements to assess interp…
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