Coronial

128 results for blood tests

WAhospital2026-03-26

Inquest into the Death of Sandipan DHAR

1y · Male·Complications of acute lymphoblastic leukaemia

…eferred to Joondalup Health Campus ED on 22 March, with the GP's referral letter specifically recommending blood tests to exclude sepsis. The ED consultant diagnosed viral tonsillitis and ordered respiratory and urine t…

emergency medicinegeneral practicediagnosticcommunicationparacetamol
QLDhospitalPodcast2008-10-10

Maxfield, Annette

62y · Female·Haemorrhage caused by abdominoperineal excision of the rectum

…rous and unnecessary. When massive haemorrhage occurred, management was delayed by inadequate preoperative blood work, blood product availability, and failure of the anaesthetist to order critical tests promptly. The co…

colorectal surgeryanaesthesiadiagnosticproceduralsevoflurane
VIChome2013-05-21

Finding into death of John Crivera

31y · Male·Quetiapine toxicity in a man consuming sertraline and mirtazapine

… non-compliance (retrospective pill counts showed he stopped lithium and valproate around September). When blood tests were ordered in late November, they were optional rather than mandatory, and he didn't attend. If co…

psychiatryemergency medicinediagnosticcommunicationquetiapine
QLDhospital2023-03-13

Timms, Peter John

71y · Male·Acute myeloid leukaemia due to transformation from chronic myelomonocytic leukae…

…tic leukaemia. He made over 40 health service requests while incarcerated, including repeated requests for blood tests starting in February 2020. A blood test ordered on 19 February 2020 was delayed 9 days and showed ab…

haematologypalliative caredelaydiagnosticoral antibiotics
QLDhospital2016-03-18

McGuane, Shirley Fay - Non-inquest findings

84y · Female·Myocardial infarction

…th ECG showing atrial fibrillation and new right bundle-branch block was not investigated with troponin or blood tests despite this indicating possible myocardial infarction. Significant anaemia (Hb 72, down from 127) a…

surgerycardiologydiagnosticcommunicationwarfarin
NSWhospital2011-11-11

Coroner's Finding: John Reginald Beech

64y · Male·Postoperative intra-abdominal bleeding from pancreatic artery injury and its con…

… that was not recognized initially. The anaesthetist incorrectly diagnosed anaphylaxis and failed to order blood tests, though he sought ICU input. The surgeon waited for results but then prioritized another patient's o…

anaesthesiacolorectal surgerydiagnosticdelaymorphine
NSWhospital2018-12-03

Inquest into the death of Troy Almond

1y · Male·Septicaemia due to Streptococcal (Beta Haemolytic Group A) infection

…ng signs of toxicity and persistent tachycardia throughout his 4-hour ED stay, Troy was discharged without blood tests to investigate possible bacterial infection. He deteriorated overnight and died from Group A Strepto…

emergency medicinepaediatricsdiagnosticsystemparacetamol
VIChospitalNew2026-08-21

Finding into death of Susanne Keating

64y · Female·Presumed massive pulmonary embolus

…icians appropriately considered PE as differential diagnosis and ordered appropriate investigations: CTPA, blood tests (D-dimer, troponin), and ECG. However, these critical tests were not performed during her 6-hour ED …

emergency medicinegeneral practicedelaysystem
SAhospital2013-08-15

Coroner's Finding: STOCK Anthony Douglas

64y · Male·hypoxic-ischaemic encephalopathy complicating cardiac arrest due to retroperiton…

…enoxaparin (100mg twice daily) initiated under an orthopaedic protocol. Critical failings included: (1) no blood tests performed after admission to monitor haemoglobin or renal function despite therapeutic anticoagulati…

orthopaedic surgeryemergency medicinediagnosticcommunicationenoxaparin
VIChospital2015-04-29

Finding into death of John Manias

63y · Male·Multisystem organ failure, pneumonitis and sepsis; complications arising from a …

…spital with rib fractures and pelvic injuries. Clinical deterioration occurred over several days. Critical blood tests showing elevated creatinine (229 mmol/L) and CRP (401.3) were taken on 8 March 2008 but not reviewed…

trauma surgeryorthopaedic surgerydiagnosticcommunicationceftriaxone
VIChospital2015-07-01

Finding into death of Robert Charles Avery

86y · Male·Septic shock secondary to urosepsis

…luid restriction, bowel preparation, and insulin adjustment. Despite overnight clinical deterioration (low blood pressure, rectal bleeding, poor oral intake), he was discharged on day 2. An emergency physician reviewed …

surgerygastroenterologycommunicationsystemmixtard insulin
VICcommunity2016-01-19

Finding into death of Benjamin Hodgson

29y · Male·Diabetic ketoacidosis

…and hypertension. The GP diagnosed a urinary tract infection and prescribed antibiotics, arranging fasting blood tests for the following day. Mr Hodgson was found deceased the next morning from diabetic ketoacidosis wit…

general practicepathologydiagnosticdelaycefalexin
ACThome2018-12-20

Inquest into the death of Lesley Kaye Hasleby

61y · Female·respiratory failure consistent with end-stage chronic obstructive airways disord…

…rvous system depressants (dothiepin and oxazepam) for years without adequate in-person review. Critically, blood tests in June 2011 showed worsening hypoxia, but the GP did not review the patient. In September, prescrip…

general practicerespiratory medicinediagnosticcommunicationdosulepin
VIChospital2018-06-14

Finding into death of Ian John Gilbert

77y · Male·Complications of methotrexate toxicity in a man with chronic renal impairment, c…

…oxicity after a GP prescribed it at an inappropriate daily dose (5mg daily) for psoriasis without baseline blood tests. The dispensing pharmacist recognized the dangerous dose, called the doctor, but ultimately dispense…

general practicepharmacydiagnosticmedicationmethotrexate
VICmental health2015-05-27

Finding into death of Waldemar Ariel Ogon

45y · Male·spontaneous lethal arrhythmia arising from focal myocardial fibrosis

…itical issue was inadequate visual observations overnight—the patient had refused physical examination and blood tests on admission. Observations at 7:15-7:25am suggested he was sleeping and breathing, but post-mortem e…

psychiatryforensic medicinecommunicationsystemolanzapine
QLDhospital2011-06-10

Conlan, Kathleen Anne

70y · Female·Cardiac arrest caused by a combination of gastric haemorrhage and pneumonia exac…

…sease. She presented with severe epigastric pain and was appropriately admitted for investigation. Initial blood tests and CT scan showed no evidence of gastrointestinal bleeding. Her symptoms improved and she was disch…

emergency medicinesurgerydelaymorphine
SAaged care2014-03-21

Coroner's Finding: MORGAN Beryl Jean

73y · Female·pneumonia and renal failure with hyperthermia

…her care: inadequate monitoring for dehydration despite clinical signs (severe sweating, tremors, elevated blood sugars), delayed medical review by her GP (Dr G.), inappropriate use of intramail for urgent communication…

general practicegeriatric medicinediagnosticcommunicationhaloperidol
VIChospital2024-08-12

Finding into death of Heather Maree Smith

64y · Female·Complications of hospital acquired pneumonia and COVID-19 infection

…on-compliance with treatment, including refusal of thickened fluids despite dysphagia, and difficulty with blood tests and interventions. She was discharged on 23 December 2022 against the backdrop of respiratory deteri…

general practiceemergency medicineantibiotics
QLD2017-08-04

Mrs H - Non-inquest findings

76y · Female·Acute renal failure due to dehydration due to upper gastrointestinal bleed

…onic pain was admitted to a small rural hospital on 1 April 2015 with haematemesis secondary to NSAID use. Blood tests were ordered on admission but not transported to the district hospital for testing until 3 April, de…

general medicinegastroenterologydiagnosticcommunicationibuprofen
SAhospital2022-04-13

Coroner's Finding: Cook, Courtney Liza

20y · Female·multi-organ failure due to polypharmacy overdose

…polypharmacy overdose (13 grams of paracetamol among 78 tablets). She was admitted to the ED where initial blood testing at 3 hours post-ingestion showed 757 μmol/L paracetamol (below 1000 μmol/L threshold), and NAC was…

emergency medicinegastroenterologydiagnosticcommunicationparacetamol

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