83y · Male·pulmonary fat embolism complicating interstitial lung disease
…orted to hospital and underwent emergency surgery for the fracture with neurovascular compromise. During induction of anaesthesia, his blood pressure dropped and he suffered cardiac arrest from which he could not be res…
42y · Female·Global cerebral ischaemia in a setting of anaesthesia
A 42-year-old woman died from global cerebral ischaemia following cardiac arrest during anaesthesia for a late-term termination of pregnancy. The anaesthetist, Dr McAllister, failed to obtain or ensure a…
0y · Male·hypoxic ischaemic encephalopathy
…mergency caesarean section delivery on 1 March 2005. After artificial rupture of membranes during labour induction, the foetus developed severe, sustained bradycardia lasting approximately 30 minutes before delivery. Th…
91y · Male·Complications following cardiac arrest in the setting of anaesthetic induction d…
…arrest from suxamethonium died from complications following anaphylaxis to rocuronium during anaesthetic induction for emergency small bowel obstruction surgery. His GP records documented allergy to both suxamethonium a…
Male·Hypoxic brain injury arising from intra-uterine asphyxia (causative factors unas…
…am Keays was a neonate born at 37 weeks via emergency caesarean section for fetal distress during labour induction with Syntocinon. He was stillborn with Apgar scores of 0/0/1, requiring 12 minutes of resuscitation to a…
87y · Female·Pulmonary artery rupture complicating pulmonary artery catheter insertion in a w…
…was inserted pre-operatively for haemodynamic monitoring. Approximately 45 minutes later, at anaesthetic induction, moderate blood was observed in her oral cavity—a known clinical sign of PAC-related pulmonary artery in…
46y · Male·Hypoxic ischaemic brain injury complicating a cardiac arrest during anaesthetic …
A 46-year-old male underwent elective inguinal hernia repair at a private hospital. During anaesthetic induction, he experienced cardiac arrest. The endotracheal tube (ETT) was visualized passing through the vocal cor…
35y · Female·Unascertained
…al management during the acute crisis was appropriate, but systemic issues contributed to the death. The induction was scheduled outside normal working hours when consultant staff were off-site and blood bank services w…
1y · Female·unrecognised oesophageal intubation
A 19-month-old girl died from unrecognised oesophageal intubation during anaesthesia for finger laceration repair. The anaesthetic team failed to recognise multiple clinical indicators of …
28y · Female·Anaphylactic reaction to anaesthetic drug (suxamethonium), with underlying coron…
A 28-year-old woman died during routine dental extraction under general anaesthesia at a regional hospital. Despite competent initial airway management, she developed severe respiratory d…
76y · Male·multiple organ failure due to large volume aspiration of gastric contents during…
…carrow, 76, died from multiple organ failure following aspiration of gastric contents during anaesthetic induction for cystoscopy on 15 August 2015. He had undergone colorectal surgery on 30 July with complications incl…
0y · Female·Pulmonary hypoplasia in the setting of ascending maternal genital tract infectio…
…ondary to ascending maternal genital tract infection. She was born via emergency caesarean section after induction of labour for brow presentation. Despite resuscitation efforts, she remained bradycardic and died 22 min…
15y · Male·right haemothorax due to lacerations of right lung
A 15-year-old male died from right haemothorax due to lung lacerations sustained in a high-speed motor vehicle collision. The vehicle, driven by an unlicensed 15-year-old driver with faulty brakes, crashed into a tree af…
37y · Female·Hypoxic brain injury complicating cardiorespiratory arrest during manual removal…
A 37-year-old primigravida with gestational diabetes was admitted for labour induction at 37 weeks. Following vaginal delivery and delayed placental separation, manual removal of placenta was…
0y · Female·Fetal demise due to placental abruption and sepsis secondary to chorioamnionitis…
Ashlee Reindl died hours after birth in 2019 following a prolonged induction of labour complicated by fetal distress and chorioamnionitis. A catastrophic placental abruption occurre…
55y · Male·ruptured dissection of the thoracic aorta
… prompted urgent transfer to RPH where CT imaging confirmed type A aortic dissection. He deteriorated on induction of anaesthesia and died despite resuscitation efforts. The coroner found medical care at SDH was appropr…
0y · Female·Cerebral hypoxia due to placental abruption
…ary to placental abruption following emergency caesarean section. Gestational diabetes indicated planned induction at term. At 2050 hours, antepartum haemorrhage and pathological CTG changes occurred. Critical delay occ…
0y · Male·severe hypoxic ischaemic encephalopathy secondary to uterine rupture
…rely hypoxic at birth and died 3 days later. Key issues: Ms M had risk factors including previous failed induction and untried pelvis; limited documentation of informed consent discussions; no continuous fetal monitorin…
0y · Male·Perinatal hypoxic ischaemic encephalopathy with severe diffuse cortical necrosis…
…ntocinon-induced contractions and delayed obstetric intervention. The infant was delivered at term after induction for post-dates pregnancy. During labour, syntocinon infusion was increased to 120 ml/hour without adequa…
0y · Male·Head injury sustained in a difficult delivery including head impaction and caesa…
Baby Sidney died from severe hypoxic-ischaemic encephalopathy caused by head impaction during a difficult vaginal delivery attempt and subsequent caesarean section at 6 days old. The coroner found that medical care fell …
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