20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…
…e-mask ventilation through a displaced tube, causing bilateral tension pneumothoraces. Delays in emergency airway management, failure to use laryngeal mask airway, and failure to perform timely finger thoracostomy signif…
68y · Male·Complications of a witnessed airway obstruction from food bolus in a man with dy…
A 68-year-old man with dysphagia and bipolar disorder died from airway obstruction and aspiration pneumonia after choking on a sandwich brought by his wife during a supervised h…
33y · Male·Aspiration due to alcoholic intoxication; coronary atherosclerosis contributed
…te sedation for aggressive behaviour, he vomited copiously, aspirating semi-solid food that obstructed his airway. Emergency attempts at intubation and surgical airway management were unsuccessful. The coroner found no c…
7y · Female·aspiration pneumonia leading to multi-organ failure in a female child with compl…
…i-organ failure. Born with severe perinatal brain injury, she had complex lifelong medical needs including airway management with nasopharyngeal airway, supplementary oxygen, and seizure control. Initially cared for at h…
40y · Male·Aspiration pneumonia
… and vomiting, imaging suggested small bowel obstruction, and he became agitated during nasogastric tube insertion. Ketamine was administered for sedation, he vomited and aspirated during tube placement, requiring emerg…
1y · Male·hypoxic brain damage due to laryngeal obstruction from foreign body (metal screw…
…ics arrived within 6 minutes but struggled to visualize and remove the screw due to blood and vomit in the airway. An intensive care paramedic arrived and successfully removed the screw via laryngoscopy with Magill's for…
26y · Male·acute cocaine and alcohol toxicity
…rmed the police officers' response was exemplary and appropriate throughout, including seizure management, airway positioning, and timely resuscitation. The death was not preventable—it resulted from acute toxicity from …
76y · Female·Ludwig's angina
… arrangements made for transfer to a tertiary centre. However, staff failed to recognise the risk of rapid airway compromise despite documented clinical deterioration (increased noise in breathing, worsening swelling, di…
31y · Male·Upper airway obstruction due to pharyngeal abscess caused by dental abscess, whi…
Karl Scholz, 31-year-old male, died from upper airway obstruction due to pharyngeal abscess originating from untreated dental infection. He presented with sever…
28y · Male·asphyxiation following severe swelling to the larynx due to anaphylactoid reacti…
…lausible; early recognition allows prompt adrenaline administration which may alter outcomes. The surgical airway was difficult given massive swelling but appropriately performed. Broader learning: anaphylaxis can be tri…
31y · Male·Status epilepsy secondary to cerebral cavernoma
…expert commentary that earlier monitoring equipment application, earlier lateral repositioning, and closer airway assessment could have been beneficial. No clinical errors were identified as causative, though positioning…
81y · Female·aspiration pneumonia on a background of severe dysphagia and right hemiplegia
An 81-year-old woman with severe dysphagia and right hemiplegia from previous stroke died of aspiration pneumonia after vomiting while sleeping following PEG feeding. She was subject to guardianship and detention under t…
50y · Male·Hypoxic-ischaemic encephalopathy secondary to choking on food bolus
… dispatcher delayed recognition of cardiac arrest. Paramedics initially failed to visualise and remove the airway obstruction due to inexperience with laryngoscopy and faulty equipment; a critical care paramedic removed …
78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …
… from hypoxic ischaemic encephalopathy following an acute post-surgical arterial bleed that obstructed her airway after hemithyroidectomy. The bleeding complication occurred when she coughed after taking oral pain medica…
58y · Female·lymphangitic carcinomatosis leading to hypoxaemic respiratory failure and cardia…
…015, and during resuscitation following cardiac arrest, adrenaline was not administered per guidelines and airway management issues occurred. She died of lymphangitic carcinomatosis, a rare gastric cancer undiagnosed ant…
11y · Female·pneumonia complicating cytomegalovirus embryopathy
Queenie Michaels, an 11-year-old Aboriginal girl with cytomegalovirus embryopathy and severe physical and cognitive disabilities, died from pneumonia at home while in government care. She had been fostered by Mr and Mrs …
0y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…
…as a sign of tube malpositioning, maintain capnography during manual ventilation and CPR, and ensure clear airway role assignment during resuscitations.
19y · Female·echovirus type 9 infection (myocarditis and pneumonitis)
A 19-month-old child died of echovirus type 9 myocarditis and pneumonitis after rapid deterioration while on holiday. She presented to a small rural hospital with fever, altered consciousness, and seizure activity. The t…
39y · Male·Hypoxic brain injury due to respiratory obstruction following surgery for dental…
…ppeared to recover well in the recovery room. However, approximately 2 hours post-operatively, progressive airway swelling developed rapidly, causing complete obstruction. The initial re-intubation attempt was oesophagea…
18y · Female·Acute Alcohol Toxicity with Early Pneumonia and Aspiration
…s from alcohol intoxication is a medical emergency requiring immediate hospital admission and professional airway management. Those present lacked understanding of alcohol toxicity, respiratory depression, and aspiration…
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