Coronial

134 results for blood transfusion

SAhospital2005-01-18

Coroner's Finding: SQUIRES Dorothy Alberta

90y · Female·incompatible blood transfusion resulting in haemolysis and multi-organ failure c…

…year-old woman with acute myocardial infarction and cardiogenic shock died after receiving an incompatible blood transfusion (A- instead of O+), which caused haemolysis and multi-organ failure. The registered nurse admi…

cardiologyintensive careproceduralcommunication
SAhospital2001-11-08

Coroner's Finding: STEWART Margaret May

77y · Female·multi-organ failure due to massive transfusion-induced coagulopathy following re…

A 77-year-old woman died from multi-organ failure following massive transfusion-induced coagulopathy after a retroperitoneal haemorrhage of unknown origin post-knee replacement surger…

surgeryvascular surgerycommunicationsystemdalteparin
VIChospital2025-08-19

Finding into death of Con Koumis

43y · Male·complications of decompensated liver failure due to occult sepsis and retroperit…

Con Koumis, a 43-year-old man with beta-thalassaemia major requiring regular blood transfusions, died from decompensated liver failure complicated by occult sepsis and retroperitoneal haemo…

haematologyhepatology
QLDhospital2017-10-17

SWK - Non inquest findings

78y · Female·multi-organ failure due to haemorrhage into the abdomen, pelvis and retroperiton…

…ltiple comorbidities, previous spinal surgery with persistent pain, osteoporosis, and religious refusal of blood transfusion. During surgery, she became hypotensive and tachycardic during the posterior approach but surg…

spinal surgeryorthopaedic surgeryproceduraldiagnosticaramine
SAhospital2010-07-09

Coroner's Finding: STEMMER Jessica Lee and MAHAR Thomas William

Jessica: disseminated intravascular coagulation following haemorrhage (subgaleal…

…th deliveries were technically appropriate. Jessica's death may have been preventable: she required urgent blood transfusion which was ordered but not delivered before her collapse—Dr B. did not adequately follow up on …

obstetricsneonatologydelaycommunication
VIChospital2014-05-28

Finding into death of Margaret Webber

48y · Female·Aspiration of stomach contents and pneumonia, following cardiac arrest

…treated DKA as the primary diagnosis while monitoring for bleeding with serial haemoglobin measurements. A blood transfusion was ordered at 4.45pm when haemoglobin fell to 84g/L, meeting international guideline criteria…

emergency medicineendocrinologyinsulin infusion
SAhospital2003-03-12

Coroner's Finding: STOLL Ruth Sophie

71y · Female·massive acute haemolysis leading to severe anaemia and multi-system failure as a…

Ruth Stoll, 71, died from massive acute haemolysis and multi-system failure after receiving incompatible blood transfusions during aortic aneurysm repair. Pre-operative blood samples from Stoll and another patient (Ko…

cardiothoracic surgeryanaesthesiadiagnosticprocedural
VICcommunity2019-01-31

Finding into death of Pauline Mary Riordan

61y · Female·injuries sustained in a motor vehicle collision as a passenger

… care including fluids and analgesia, the extended extrication time delayed definitive treatment including blood transfusion available only at hospital. Expert evidence indicated that earlier extraction might have impro…

emergency medicinetrauma surgerydelaymorphine
SAhospital2010-02-04

Coroner's Finding: KRIVITCH Olga

81y · Female·hypovolaemic shock following bleeding from the site of a femoral angiogram

…esulting in massive undetected haemorrhage; over 4-hour delay between identifying haemoglobin of 54 and transfusion; and lack of experienced senior staff supervision. The Vascular Surgery Unit had no registrars on duty,…

vascular surgeryradiologydiagnosticmedicationheparin
NSWhospital2017-06-09

Inquest into the death of Colin HAY

69y · Male·Waldenstrom's Macroglobulinemia, a type of non-Hodgkin lymphoma

…on with chemotherapy, but relapsed in October 2015. Despite multiple cycles of chemotherapy and supportive blood transfusions, his condition deteriorated progressively. The coroner found that Mr Hay received healthcare …

haematologyoncology
SAhospital2001-09-04

Coroner's Finding: CHESTER George Spencer

18y · Male·multiple injuries

…rom the vehicle and suffered a closed head injury with subdural haematoma and severe pelvic fractures with blood loss. First aid at the scene was appropriate given his catastrophic injuries. Key clinical lessons: the se…

emergency medicinetrauma surgery
QLDhospital2017-07-31

Mrs NSM - Non-inquest findings

81y · Female·left haemothorax and mediastinal haemorrhage from the insertion site of the perm…

…e clinical indicators; (3) inadequate senior medical involvement in post-operative management; (4) delayed blood transfusion (not started until 2:50 am despite evidence of bleeding from midnight); (5) difficulty accessi…

cardiologyintensive carediagnosticcommunicationglyceryl trinitrate
SAcommunity2006-02-22

Coroner's Finding: SINCLAIR-SPAAN Christopher James

21y · Male·Closed head injury and retroperitoneal and pelvic haematoma due to fractured pel…

…rauma scenes despite protocol ambiguity—they could provide additional hands, coordinate resources, arrange blood transfusion, and detect clinical errors like the imperfectly positioned endotracheal tube; (2) Wide-bore I…

intensive caretrauma surgerycommunicationsystem
QLDhospital2026-02-18

Non-inquest findings into the death of Mr C

62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (su…

…ion and IVC involvement. Multiple intraoperative factors contributed to poor outcomes: late recognition of blood loss, delay in activating massive transfusion protocol, loss of central line preventing vasopressor admini…

urologygeneral surgerydiagnosticcommunicationmetaraminol
TAShome2016-01-29

Coroner's Finding: Smart, Joshua David

28y · Male·Brain death resulting from exsanguination and hypovolaemic arrest due to severed…

…iate first aid, CPR administered by his brother, rapid ambulance response, emergency surgery with multiple blood transfusions, and intensive care support at Launceston General Hospital, the extent of blood loss proved i…

paramedicineemergency medicine
WAhospital2005-12-09

Inquest into the Death of Laura Marguerite Sinclair

31y · Female·Post-partum Haemorrhage associated with Amniotic Fluid Embolism and Uterine Hypo…

…a. She underwent emergency caesarean section for foetal distress at Peel Health Campus, experiencing heavy blood loss (estimated 1500ml). Although initially stable post-operatively, she re-bled significantly (1000ml) wi…

obstetricsanaesthesiadiagnosticcommunicationpethidine
QLDhospital2008-10-10

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
NSWhospital2025-02-28

Inquest into the death of Heather Winchester

75y · Female·multiple organ failure due to severe anaemia secondary to blood loss post electi…

…ccurred: the surgical and anaesthetic teams held conflicting understandings about whether she would accept blood transfusion—the surgeon believed she refused all blood products based on her consent form and Jehovah's Wi…

gynaecologyanaesthesiacommunicationsystem
VIChospital2018-10-11

Finding into death of John Richard Connelly

78y · Male·Complications of blood loss from femoral fracture sustained in harness riding in…

…ding risk; correcting hypovolaemia in uncontrolled bleeding can paradoxically worsen outcome by increasing blood pressure and rebleeding. The death was not preventable given the injury severity and clinical state on par…

emergency medicinetrauma surgerydelaysystemwarfarin
TAS2020-06-01

Coroner's Finding: Tonner, Justin Michael

39y · Male·Hypovolemic shock due to blood loss resulting from multiple stab wounds, particu…

Justin Michael Tonner, aged 39, died from hypovolemic shock due to blood loss from multiple stab wounds inflicted during a violent altercation. The fatal injury was a stab wound t…

emergency medicinetrauma surgerymethamphetamine

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