Coronial

51 results for bag-mask ventilation

VIChospital2012-07-16

Finding into death of Ruben Chand

42y · Male·Hypoxic encephalopathy in the setting of recent acute myocardial infarction with…

…e to use a bougie despite difficulty, lack of capnography confirmation, and critically, absence of manual bag-mask ventilation between intubation attempts. The endotracheal tube was misplaced in the oesophagus for 17-22 …

intensive careanaesthesiaproceduralcommunicationpropofol
SAhospital2016-02-08

Coroner's Finding: FIDGE Patricia Ann

67y · Female·choking and ischaemic heart disease

…her right main bronchus. Staff responded promptly to her gurgling sounds and attempted resuscitation with bag-mask ventilation, but she was not intubated given her DNR status and poor prognosis. The coroner found her car…

emergency medicinepsychiatryrisperidone
TAShospital2021-07-02

Coroner's Finding: HB

8y · Male·acute exacerbation of chronic asthma

An 8-year-old boy with undertreated chronic asthma presented to North West Regional Hospital with acute exacerbation. Initial assessment underestimated severity. Despite initial improvement with salbutamol, ipratropium a…

paediatricsemergency medicinediagnosticcommunicationfluticasone/salmeterol
VIChome2016-04-01

Finding into death of Michelle Lorraine Griffin

48y · Female·Acute respiratory failure (cerebral hypoxia) in a woman dependent on non-invasiv…

…in, 48, with motor neurone disease, died from acute respiratory failure while dependent on non-invasive ventilation (NIV) at home. A carer, Julie Manessis, was caring for her when the humidifier tipped over, water enter…

respiratory medicineneurologycommunicationsystemmorphine
TAScommunity2023-12-15

Coroner's Finding: Macpherson James Edward

29y · Male·blunt trauma of the chest

…nd a paramedic (who worked part-time at the bike park). Advanced interventions including bag-valve-mask ventilation, emergency decompression with a bicycle spoke under remote consultant guidance, CPR, and helicopter ret…

emergency medicineretrieval medicine
ACT2019-06-26

Inquest into the death of Mark Anthony O’Connor

40y · Male·Multiple drug toxicity, being either an overdose due to methylamphetamine alone,…

…fficers initiated CPR within seconds, ACT Health staff arrived within three minutes with bag-valve-mask ventilation, and ambulance officers arrived 15 minutes later. The coroner found no clinical errors in emergency man…

emergency medicinetoxicologymethamphetamine
VIC2019-12-05

Finding into death of Serafina Pirrottina

57y · Female·Complications of muscular dystrophy

A 57-year-old woman with longstanding muscular dystrophy and newly diagnosed cardiomyopathy died from complications of her underlying condition. She became acutely unwell overnight at her residential support facility wit…

respiratory medicineemergency medicinerosuvastatin
NSWhospital2023-10-31

Inquest into the death of Adam Fitzpatrick

20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…

…not occur for approximately 46 minutes. Staff attempted blind bougie instrumentation and bag-valve-mask ventilation through a displaced tube, causing bilateral tension pneumothoraces. Delays in emergency airway manageme…

intensive careanaesthesiadiagnosticproceduralrocuronium
VIChospital2025-12-01

Finding into death of Larelle Sheridan Dean

51y · Female·Multiorgan failure in the setting of WHO Class III obesity, chronic excessive al…

…y failure, acute kidney injury, and constipation. Despite appropriate management including non-invasive ventilation, antibiotics, and diuresis, she deteriorated with recurrent hypoxic episodes and apnoea. A MET call on …

general medicineemergency medicinehydromorphone
QLDhospital2026-07-24

Inquest into the death of Wren Marion Preo

<1y · Female·Hypoxic ischaemic encephalopathy caused by respiratory failure following severe …

Baby Wren Marion Preo, born at term after precipitate labour at Atherton Hospital in Queensland, died at approximately 8 hours of age from hypoxic ischaemic encephalopathy secondary to severe meconium aspiration that occ…

midwiferyneonatologybenzylpenicillin
QLD2021-01-22

Miller, Cindy Leigh

44y · Female·Mixed drug toxicity (methylamphetamine, amphetamine, tramadol)

Cindy Leigh Miller, aged 44, died in Ipswich Watchhouse on 21 April 2018 from mixed drug toxicity involving methylamphetamine, amphetamine, tramadol and other substances. A concealed clip-seal bag containing 5mg pure met…

forensic medicineemergency medicinesystemproceduralmethamphetamine
VIChospital2019-09-16

Finding into death of Marco Angelo Virgona

45y · Male·Aspiration pneumonia with acquired brain injury as a contributing factor

Marco Virgona, a 45-year-old man with acquired brain injury and epilepsy, died from aspiration pneumonia at Frankston Hospital on 23 May 2017. He initially presented to Ambulance Victoria in the morning with vomiting and…

emergency medicineintensive carewarfarin
VIChome2022-10-31

Finding into death of Master S

13y · Male·Asthma

Master S was a 13-year-old Aboriginal boy with severe persistent asthma who died at home on 13 November 2019. He was found unresponsive with his nebuliser mask on his face. The coroner accepted that death resulted from a…

respiratory medicineallergy and immunologysystemfluticasone/vilanterol
TAShome2023-11-14

Coroner's Finding: de-identified OV

<1y · Male·hypoxic brain damage due to laryngeal obstruction from foreign body (metal screw…

An 11-month-old boy died from hypoxic brain damage following aspiration of a 2cm metal screw that lodged in his larynx. The child was left briefly unsupervised at home when he ingested the screw and began choking. Parent…

paediatricsemergency medicineadrenaline
VICcommunity2026-03-04

Finding into death of Anthony Laurence Parisi

39y · Male·Multidrug toxicity (GHB, methylamphetamine, ketamine) in a setting of restraint …

Anthony Parisi, 39, died from multidrug toxicity (GHB, methamphetamine, ketamine) in a setting of police restraint and moderate coronary artery atherosclerosis. He consumed large quantities of GHB and methamphetamine on …

emergency medicineintensive caregamma-hydroxybutyrate
NTcommunity2004-12-14

Inquest into the death of Nikita Anderson

<1y · Female·bronchopneumonia caused by hypoxic brain damage caused or contributed to by meni…

A 9-month-old Aboriginal girl died from bronchopneumonia caused by hypoxic brain damage following cardiorespiratory arrest due to meningitis and seizures. During resuscitation at a rural GP clinic, a CO₂ cylinder was ina…

general practicepaediatricsproceduralsystemadrenaline
NSWhospital2018-12-04

Inquest into the death of June Nutter

58y · Female·lymphangitic carcinomatosis leading to hypoxaemic respiratory failure and cardia…

June Nutter, a 58-year-old woman presenting with weight loss, anorexia, and unexplained shortness of breath, underwent gastroscopy and colonoscopy at a private hospital to investigate suspected gastric pathology. She had…

anaesthesiagastroenterologymedicationproceduralfentanyl
QLD2010-04-16

Nguyen, Luong Bang

31y · Male·Subarachnoid haemorrhage due to or as a consequence of a ruptured large fusiform…

A 31-year-old man with long-standing intravenous drug use and hepatitis C died in prison custody from a ruptured mycotic aneurysm causing subarachnoid hemorrhage. He collapsed in his cell after lock-down without prior wa…

emergency medicineintensive carequetiapine
VIChospital2011-12-01

Finding into death of Tyler Di Blasi

1y · Male·Parainfluenza, pneumonitis and asthma; haemorrhagic mucositis of the bowel and g…

Tyler Di Blasi, aged 14 months, died from complications of acute lymphoblastic leukaemia (ALL) treatment. He developed parainfluenza pneumonitis, severe asthma, chemotherapy-induced neutropenia, thrombocytopenia, and gas…

intensive careoncologychemotherapy
SAhospital2025-06-11

Coroner's Finding: OHalloran, Emma Louise

48y · Female·multiple drug toxicity consisting of flecainide, lorazepam and diazepam

A 48-year-old woman died from multiple drug toxicity (flecainide, lorazepam, diazepam) following a deliberate overdose. She was located by police after a search and detained under the Mental Health Act. Critical delays o…

cardiologygeneral practicesystemcommunicationflecainide

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