Coronial

181 results for ischaemic brain injury

NSWhospital2018-12-17

Inquest into the death of Jarrod Wright

42y · Male·Cardiac arrest following hypoxic ischaemic encephalopathy, likely due to E.coli …

…:15pm, no alarm sounded because he had also disconnected the monitoring module. He suffered severe hypoxic brain damage and died 6 days later. Key lessons: ensure escalation of care and nursing ratios match clinical nee…

intensive careinfectious diseasescommunicationsystemmeropenem
SAcommunity2011-05-12

Coroner's Finding: KILTIE Andrew

52y · Male·clozapine toxicity

Andrew Kiltie, 52-year-old Aboriginal man, died from clozapine toxicity on 26 December 2007. He had been on clozapine 400mg daily for 5 years with significant clinical benefit for aggressive behaviour and psychosis, enab…

psychiatrycardiologyclozapine
VICcommunity2026-05-07

Finding into death of Elizabeth Susan Edwina Ferris

44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…

…ris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was found unconsci…

psychiatryintensive carediagnosticcommunicationheroin
SAhospital2001-07-13

Coroner's Finding: TRIMBOLI Jayden Tyler

0y · Male·hypoxic-ischaemic encephalopathy due to prolonged fetal bradycardia

Jayden Tyler Trimboli, aged 6 days, died from hypoxic-ischaemic encephalopathy caused by a prolonged fetal bradycardia episode between 11:10pm and 11:50pm on 18 Septemb…

obstetricsmidwiferycommunicationsystemprostaglandin gel
VICmental health2019-09-19

Finding into death of Vanna Vassallo

68y · Female·Complications of a right subdural haemorrhage (palliated), sustained in a fall

…esulting in massive intracranial bleeding. Clinical assessment after earlier falls may have underestimated injury risk. The coroner found the level of care appropriate and fell prevention strategies adequate, though note…

psychiatrygeriatric medicinepossibly_preventablefluphenazine decanoate
VIChospital2008-08-15

Finding into death of William Grant Keays

Male·Hypoxic brain injury arising from intra-uterine asphyxia (causative factors unas…

…0/0/1, requiring 12 minutes of resuscitation to achieve cardiac output. He died 7 hours later from hypoxic brain injury due to intra-uterine asphyxia. Clinical issues included: inadequate informed consent regarding indu…

obstetricsneonatologycommunicationdelayoxytocin
VIChospital2015-12-09

Finding into death of Benjamin David Johnston

36y · Male·Global hypoxic brain injury due to hanging

Benjamin Johnston, a 36-year-old male, died by hanging after six weeks of varenicline (Champix) treatment for smoking cessation. Two weeks before death, his partner noted significant behavioral changes: withdrawal, irrit…

general practicepsychiatryvarenicline
NSW2011-07-01

Coroner's Finding: Michael Peter Magro

40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…

…l Peter Magro, a 40-year-old male inmate at a correctional facility, died on 27 December 2008 from hypoxic brain injury following cardiac disease and severe pneumonia. Critical failures in prison healthcare were identif…

correctional healthgeneral practicediagnosticcommunicationmethadone
NThospital2009-05-28

Inquest into the death of Declan McConville

0y · Male·acute hypoxic damage caused by shoulder dystocia during delivery

…2007. He was stuck in the birth canal for approximately 15 minutes before delivery, causing severe hypoxic brain injury. He died 8 days later from acute hypoxic damage and multiple organ failure. The coroner found the v…

obstetricspaediatricsproceduralsystemoxytocin
QLD2012-12-14

Mitchell, Herbert John

50y · Male·Global hypoxic brain injury suffered during cardiac and respiratory arrest cause…

…uffered cardiorespiratory arrest at 3:21pm while in the watchhouse and died the following day from hypoxic brain injury. Medical experts concluded hospitalisation after the initial QAS assessment would likely have preve…

emergency medicineintensive carediagnosticsystemalcohol
VIChome2022-10-04

Finding into death of Baby R

3y · Unknown·Unascertained - natural causes; evidence of aspiration pneumonia, hypoxic-ischae…

… difficulties, respiratory distress, and collapsed on day 3. Despite resuscitation, he sustained hypoxic-ischaemic brain injury and died. Autopsy revealed aspiration pneumonia and chronic villitis but no definitive caus…

obstetricsmidwiferysystemcommunication
WA2016-10-10

Inquest into the Death of Hayder SAYED

30y · Male·Acute cardiac failure in association with severe ischaemic heart disease seconda…

A 30-year-old Afghan asylum seeker died from acute cardiac failure due to severe coronary atherosclerosis while in immigration detention. He had developed a large anteroseptal myocardial infarction between 4-18 August 20…

cardiologyemergency medicinemirtazapine
NSWhospital2018-10-04

Inquest into the death of D H

56y · Male·Hypoxia and cardiac arrest with contributing conditions of Ischaemic Heart Disea…

A 56-year-old man with diabetes, ischaemic heart disease, morbid obesity, and an implanted defibrillator underwent minor toe debridement surgery. T…

anaesthesiageneral surgerydiagnosticproceduralpropofol
VIChospital2023-07-14

Finding into death of Reginald Desmond Benham

85y · Male·Intracranial haemorrhage in the setting of a fall in a man with multiple comorbi…

… multiple comorbidities suffered a fall at home and was transported to hospital with stroke symptoms. A CT brain scan revealed subtle subarachnoid haemorrhage (traumatic), but the VST consultant neurologist missed this …

emergency medicineneurologydiagnosticcommunicationalteplase
NSWcommunity2024-02-19

Inquest into the death of Omar Mohammad

33y · Male·Irreversible hypoxic brain injury secondary to acute cocaine toxicity

…aine whilst being arrested for trespass on 10 August 2020. He died 44 days later from irreversible hypoxic brain injury secondary to acute cocaine toxicity. Police attending the scene identified he was acutely unwell an…

emergency medicinetoxicologycommunicationdelaycocaine
VIChospital2014-05-29

Finding into death of Lilian Olive Blanche McClurkin

61y · Female·Peritonitis due to anastomotic leak at gastrectomy site; pathological obesity as…

… three days post-operatively before bursting on day three, causing sudden cardiac arrest and fatal hypoxic brain injury. Clinical lessons include: difficulty detecting post-operative deterioration in obese patients (abd…

bariatric surgerygeneral surgerycommunicationsystemtramadol
QLDhospital2026-05-07

Non-inquest findings into the death of Lucy Campbell

0y · Female·Severe hypoxic ischemic encephalopathy due to brain injury from complicated assi…

Lucy Margaret Campbell died eight days after birth from severe hypoxic ischemic encephalopathy following complicated assisted vaginal birth at Ingham Hospital. Her mother had a low-risk pregnancy complicated by spontaneo…

obstetricsmidwiferydiagnosticcommunicationoxytocin
SAhospital2011-08-05

Coroner's Finding: LEONARD Emily Ruth and HILLMAN Glenys Anne

Female·Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perfor…

…Leonard (77) underwent laparoscopic surgery on 30 October 2008; a colon perforation from diathermy-induced injury was not recognized intraoperatively and only became apparent 6 days post-discharge, resulting in multi-org…

gynaecologyintensive carediagnosticproceduralheparin
QLDhospital2016-11-07

Bower, Malaki Ron - Non-inquest findings

2y · Male·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest secondary to up…

…wing day he suffered cardiorespiratory arrest from upper airway obstruction, resulting in severe hypoxic-ischaemic brain injury and death. Key issues: inadequate observation period; poor documentation of senior review; …

emergency medicinepaediatricsdiagnosticcommunicationnebulised adrenaline
NSWhome2019-07-05

Inquest into the death of Levai

7y · Male·Blunt force head injury with bilateral acute subdural haemorrhage, hypoxic/ischa…

Levai, a 7-year-old boy with learning difficulties, died from blunt force head trauma inflicted by his mother's boyfriend Kodi Maybir on 20 May 2013. The coroner identified systematic failures by NSW Police and FACS. Pol…

paediatricsforensic medicinediagnosticcommunication
167810

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