228 results for “airway management”
23y · Male·sea snake bite with neurotoxic venom causing neuromuscular paralysis and respira…
…ke dangers, failure to mandate puncture-resistant gloves, lack of hazard policies, and incomplete safety management documentation. The coroner concluded these breaches had causal relevance to the bite, as proper awarenes…
43y · Female·cardiac arrhythmia (unascertained), probably fatal cardiac dysrhythmia
A 43-year-old woman collapsed at home and was found in cardiac arrest after 20-25 minutes. Ambulance arrived and recognised ventricular fibrillation but failed to defibrillate for approximately 20 minutes, despite protoc…
2y · Male·Consistent with drowning
…ate CPR, retrieval by paramedics, and extensive resuscitation attempts at hospital including hypothermia management and PIPER retrieval team intervention, Hunter could not be saved. The death highlights the rapid nature …
26y · Male·gastric aspiration
A 26-year-old remanded prisoner died from gastric aspiration at Adelaide Remand Centre. He was a heroin user experiencing withdrawal, having been offered but declined infirmary treatment and methadone on arrival. Cellmat…
57y · Female·Complications of muscular dystrophy
…as per established protocol, clinical evidence indicated this did not materially affect her outcome. Her management at the residential facility, by paramedics, and in the emergency department was deemed reasonable and ap…
4y · Male·Complications of cutaneous thermal burn injuries
…e, setting fire to furniture in an open garage containing stored household goods. Despite expert medical management including emergency escharatomies, staged surgical debridement, skin grafting and intensive ICU care at …
40y · Male·Aspiration pneumonia
…tment and had no appointed person responsible. A clinical ethicist and treating team agreed conservative management was appropriate, but no formal notification to the Public Advocate was made when palliative care (includ…
46y · Male·Coronary artery atherosclerosis
… that security staffing shortages drove clinical decision-making inappropriately. No causal link between management and death established, though practice shortcomings were identified.
33y · Female·Methylamphetamine intoxication leading to agitated delirium and extreme exertion…
A 33-year-old female with a history of methylamphetamine use consumed the drug and became acutely intoxicated, exhibiting agitated delirium and bizarre behaviour searching for her son. She was violently assaulted by resi…
44y · Female·Mixed drug toxicity (methylamphetamine, amphetamine, tramadol)
…e of emergency equipment location, inability to detect subtle signs of life during cell checks, inadequate airway management due to absent resuscitation masks, and potential benefit of clearer communication about health …
57y · Male·hypoxic ischaemic brain injury complicating acute asthma
…vealed extreme sensitisation to ryegrass pollen. Key clinical lessons include the need for better asthma management, preventer medication use, allergy testing, asthma action plans, and remaining indoors during high-risk …
22y · Female·cardio-respiratory arrest as a consequence of drowning in freshwater
…; and formal documented risk assessment procedures were lacking. The coroner emphasised that formal risk management processes with documented procedures, hazard mapping, and competency assessment protocols could reduce s…
30y · Male·Complications of methylamphetamine toxicity
…ropriate. Hospital implemented recommendations for ED escalation procedures and methamphetamine overdose management.
2y · Female·Drowning in an above-ground swimming pool
…alter the outcome—the child likely died before ambulance arrival (asystolic rhythm on arrival). Hospital management was appropriate, though family support could have been better. Key lessons: supervision remains the prim…
68y · Female·Anaphylactoid reaction to intravenous CT scan contrast medium leading to cardior…
…the clinical context, but the resuscitation response lacked coordination and appreciation of anaphylaxis management principles. Better early adrenaline administration and increased fluids might have improved survival cha…
42y · Male·Drowning
…ld likely have saved or significantly improved survival chances by providing positive buoyancy and keeping airways clear of water. The coroner emphasized that life jacket use is critical for rock fishing safety, particul…
52y · Male·Polypharmacy overdose of amitriptyline and doxylamine in the context of underlyi…
A 52-year-old man with chronic facial pain, depression, obesity, cardiovascular disease and obstructive sleep apnoea died following restraint in ICU. He had ingested a polypharmacy overdose of amitriptyline and doxylamin…
50y · Male·cocaine toxicity
Jamie Frederick Ginn, 50, died from cocaine toxicity on 10 October 2023 while in custody at Perth Watch House (PWH). He had ingested approximately one teaspoon of cocaine hydrochloride; the coroner could not determine wh…
21y · Male·upper airway obstruction and plastic bag asphyxia
…-28 September 2007. The coroner found his death was potentially preventable due to systemic clinical and management failures in suicide and self-harm (SASH) risk assessment. Despite completion of a two-month psychiatric …
0y · Female·Hypoxic-ischaemic encephalopathy in the setting of chronic placental insufficien…
…stetric staff, and inadequate obstetric decision-making during labour. While unable to definitively link management failures to death (hypoxic insult timing unclear), the coroner noted the poor clinical coordination coul…
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