144 results for “resuscitation attempts”
47y · Female·ligature compression of the neck (hanging)
…August 2020. Ms Davis had significant history of substance use, mental health issues, and prior self-harm attempts. While physical health care was adequate, mental health management had several missed opportunities: a me…
0y · Female·Birth asphyxia due to tight umbilical cord around neck with meconium aspiration
Samara Lea Hoy died shortly after birth from asphyxia caused by a tight umbilical cord around her neck, complicated by meconium aspiration. The coroner identified multiple systemic failures in care. Crucially, admission …
0y · Male·Sudden Infant Death Syndrome (SIDS) Category II
Lucas Tran, a five-month-old infant in family day care, died suddenly on 18 November 2015. Despite resuscitation attempts, he could not be revived. Autopsy found no specific pathology; death was attributed to Sudden…
34y · Male·ischaemic heart disease secondary to coronary atherosclerosis as an antecedent c…
…coronary atherosclerosis. During his 5-year imprisonment, his weight increased from 86kg to 162kg despite attempts at management. He received psychiatric care only 3 times over 8 months despite complex mental health need…
38y · Female·neck compression due to hanging
…n custody. She had a complex history of psychiatric illness, drug and alcohol abuse, and multiple suicide attempts. Despite comprehensive documentation from police identifying her as suicidal, at-risk, and recently disch…
43y · Male·exsanguination from incised wounds to the arms - self inflicted
A 43-year-old man with schizophrenia, PTSD, and methamphetamine use died from exsanguination following self-inflicted incised wounds to both arms. He had been discharged from psychiatric inpatient care on 1 February 2020…
36y · Male·bronchial asthma
Nathan Reynolds, a 36-year-old Aboriginal man with severe asthma, died from bronchial asthma in prison on 1 September 2018. His death exposed critical failings in both immediate emergency response and chronic disease man…
46y · Male·atherosclerotic heart disease
Frank Albert, a 46-year-old Aboriginal man, died from atherosclerotic heart disease while incarcerated at West Kimberley Regional Prison. Although his death was caused by severe coronary artery disease unrelated to medic…
40y · Female·hypoxic ischaemic encephalopathy due to ligature compression of the neck
…ring 30-minutely observations under the approved DRA. By 7:13pm she had asphyxiated using the blanket. Resuscitation efforts continued and she remained on life support briefly but died 3 December 2021. The coroner found…
80y · Female·Pulmonary Thromboembolism in a woman with Left Femur Fracture
…:00 pm. Shortly after induction, she suffered a massive pulmonary embolism and died at 3:05 pm despite resuscitation attempts. Post-mortem confirmed acute PE with thrombotic material originating from left calf veins, li…
54y · Male·quetiapine toxicity in a man with ischaemic heart disease
… experienced a recent relationship breakdown and presented to Grampians Health (GH) with multiple suicide attempts within 72 hours. The Coroner found several key deficiencies in his mental health management: the initial …
Male·Global hypoxic-ischaemic encephalopathy
Preston Paudel, born at 37 weeks gestation after meconium-stained labour with syntocinon augmentation, was delivered severely compromised with Apgar scores of 1-1-1 and died of hypoxic-ischaemic encephalopathy. Multiple …
31y · Male·Undetermined; most likely coronary atherosclerosis leading to arrhythmia, but as…
Sparka Huntington, a 31-year-old forensic mental health patient with a history of schizophrenia, violence, and drug use, died during physical restraint by hospital security officers and nursing staff on 14 December 2003.…
23y · Male·compression of the neck, secondary to coronary arteriosclerosis
…untarily after exhibiting marked behavioral changes, he became increasingly agitated that evening. During attempts to manage his aggressive behavior, he was restrained by multiple staff members, handcuffed without medica…
27y · Male·Cardiac arrest due to cardiac arrhythmia triggered by prone restraint (some of w…
Michael Peachey, a 27-year-old First Nations man, died in custody following a police-initiated restraint during an acute psychotic episode. Over preceding days, his family repeatedly sought mental health intervention. On…
0y · Female·perinatal pneumonia in association with meconium aspiration
…escort to Northam Regional Hospital, where she arrived in severe respiratory distress and died despite resuscitation attempts. The coroner found the death arose by misadventure and concluded that had observations been t…
Three deaths with different primary causes: James Unicomb - acute toxicity due t…
Combined inquest into three deaths at Psyche South Clinic involving treatment failures: James Unicomb (22, 2005) from multi-drug overdose after naltrexone implant; Michael Poole (48, 2008) from ruptured aneurysm post-Rap…
16y · Male·complications of ligature compression of the neck (hanging)
… hours daily), inadequate mental health services despite documented suicidal ideation and prior self-harm attempts, failure to maintain appropriate supervision despite eight explicit self-harm threats on the night of dea…
42y · Female·Hypoxic ischemic encephalopathy with antecedent cause being self-caused near mis…
Tania Pauline Lioulios, a 42-year-old psychologist, died from hypoxic ischemic encephalopathy following a self-inflicted hanging in a Corrective Services transport vehicle on 4 July 2008. She had presented to mental heal…
52y · Female·laceration of the superior vena cava and right atrium during defibrillator lead …
A 52-year-old woman with a history of syncope and mitral valve prolapse, who had an implanted defibrillator, underwent a percutaneous laser lead extraction procedure at Westmead Hospital to remove and replace defective l…
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