Coronial

26 results for drainage procedures

VIChospital2011-10-06

Finding into death of John Alan Hemingway

62y · Male·Brain swelling associated with cerebral infarction; drainage acute on chronic su…

…he vehicle. Mr Hemingway was hospitalized with an acute subdural haemorrhage. On readmission for surgical drainage, he developed status epilepticus, suffered bilateral posterior cerebral artery infarction, and died. The …

neurosurgerygeneral medicineproceduralsystem
QLDhospital2006-09-13

Rawson, Robert Donald

68y · Male·Internal haemorrhage due to coagulopathy and upper gastrointestinal varices, cir…

…d multiple comorbidities, died hours after undergoing intercostal catheter insertion for pleural effusion drainage at Rockhampton Hospital. While the procedure itself was clinically appropriate and supported by tertiary …

general surgeryrespiratory medicinesystemproceduralfresh frozen plasma
VIChospital2014-08-21

Finding into death of Neville Ross

65y · Male·Cardiac tamponade whilst undergoing CT-guided pericardiocentesis; perforation of…

A 65-year-old man with history of left pneumonectomy, COPD and cardiomyopathy died from cardiac tamponade during CT-guided pericardiocentesis. Key clinical issues: (1) Necessity of procedure was questionable—patient pres…

cardiologyradiologydiagnosticprocedural
WAhospital2024-01-12

Inquest into the Death of Herbert William MACKAY

45y · Male·complications associated with metastatic adenocarcinoma of the lung, treated pal…

…ital admissions over three months for management of recurrent pleural and pericardial effusions requiring drainage procedures. The coroner found the lung cancer presented at an advanced stage with diffuse cell growth unl…

oncologycardiothoracic surgery
WAhospital2022-06-23

Inquest into the Death of Lee MILCHERDY

75y · Female·Complications including acute pancreatitis and refractory intra-abdominal sepsis…

…tion. Key clinical lessons: ensure all relevant investigation results are explicitly communicated before procedures, particularly between hospitals; maintain effective handover procedures with documented confirmation of …

gastroenterologygeneral surgerycommunicationdiagnostic
NSW2016-04-08

Inquest into the death of Paul SMITH

Male·drowning due to immersion in stormwater while trapped in a drain

Paul Smith, an Operations Supervisor at a SITA organic waste recycling facility, died after being sucked into a 30cm stormwater drain and drowning during clearing of a blockage in torrential rain. Expert evidence showed …

occupational and environmental healthemergency medicinesystemcommunication
SAhospital2006-05-19

Coroner's Finding: FALANGA Salvatore

77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…

77-year-old male died from complications of haemothorax and hypotension following drainage of pleural effusion post-coronary bypass surgery, in the setting of pre-existing renal impairment and dia…

cardiologycardiothoracic surgerydiagnosticproceduralramipril
SAhospital2003-05-08

Coroner's Finding: PRATT Shirley May

66y · Female·acute necrotising haemorrhagic mediastinitis

…r would have approximately doubled her chances of survival. Key lessons: specialists performing invasive procedures in rural settings must have formal transfer agreements with teaching hospitals, clear emergency protocol…

surgerygeneral surgerycommunicationsystemfentanyl
NSW2020-11-30

Inquest into the death of Michael MURPHY

66y · Male·complications of chronic viral liver disease

…nd no issues with his medical care or treatment. He received appropriate oncology review, underwent TACE procedures, and was managed with comfort measures including midazolam for symptom control. The death was natural an…

oncologyhepatologymidazolam
VIChospital2024-12-09

Finding into death of Elizabeth Shine

64y · Female·End stage renal failure in the setting of sepsis

…s. Although initially improving, she developed severe aspiration pneumonia following vomiting episodes. A drainage procedure was deemed unsuitable due to her Stage 5 renal failure. The coroner found no clinical managemen…

general medicinenephrologyantibiotics
VIC2013-09-06

Finding into death of Philip Stanley Dickson

58y · Male·Multiple injuries from crush injury by falling timber stack

… action was taken despite observed unsafe stacking practices. The company subsequently implemented safer procedures including height restrictions (4:1 ratio), ground stabilisation, and formal training. The coroner emphas…

occupational and environmental healthforensic medicinesystemdelay
VIChospital2025-01-22

Finding into death of Milan Rajic

40y · Male·Traumatic head injury sustained in an e-bike incident

A 40-year-old man died from traumatic brain injury sustained in an unwitnessed fall from an electric bicycle. He was riding without a helmet after consuming approximately three beers over several hours. He returned home …

neurosurgerytrauma surgery
TAScommunity2019-10-11

Coroner's Finding: Long, Anthony Edward

73y · Male·drowning

… 2018. The vessel capsized due to poor maintenance: a missing outboard pod inspection plate, unsealed pod drainage holes, and a non-functional bilge pump allowed excessive water ingress, destabilizing the vessel. Mr Long…

SAhospital2011-07-08

Coroner's Finding: BAIS Jamie Stuart

39y · Male·pneumococcal meningitis with severe cerebral oedema due to pneumococcal mastoidi…

… intracranial complications, yet the procedure was deprioritised in favour of redundant imaging and sinus drainage. Poor communication between ENT and Infectious Diseases teams, lack of senior-level coordination, and org…

ENT surgeryinfectious diseasesdiagnosticcommunicationceftriaxone
VIChome2017-12-04

Finding into death of Leigh Thomas Aiple

31y · Male·Pulmonary thromboembolism

…ensive cosmetic surgery in Malaysia (liposuction, abdominoplasty, chest lipectomy, and subsequent facial procedures) across two operations within five days. Postoperatively, he developed significant wound complications i…

plastic and reconstructive surgerygeneral surgerydiagnosticmedicationenoxaparin
WAhospital2003-08

Inquest into the Death of Richard Christopher Jankowski

39y · Male·Hypoxic brain injury due to respiratory obstruction following surgery for dental…

…for a dental abscess with cellulitis. After initial treatment with antibiotics, he underwent incision and drainage at Royal Perth Hospital. He was extubated uneventfully and appeared to recover well in the recovery room.…

anaesthesiageneral surgeryproceduralcommunicationpropofol
QLDhospital2007-11-23

Scholz, Karl David

31y · Male·Upper airway obstruction due to pharyngeal abscess caused by dental abscess, whi…

…from untreated dental infection. He presented with severe facial cellulitis and abscess following dental procedures on 17 May 2002 and underwent emergency drainage surgery. Critical issues included: premature extubation …

intensive careanaesthesiadiagnosticcommunicationamoxicillin
TAShospital2017-06-19

Coroner's Finding: Nancarrow, Maurice Cecil

76y · Male·multiple organ failure due to large volume aspiration of gastric contents during…

Maurice Nancarrow, 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 complica…

general surgeryurologydiagnosticcommunicationdiuretics
NSW2021-05-26

Inquest into the death of Liam WOLF

19y · Male·unexpected arrhythmogenic event leading to a fall from height, blunt force head …

PTE Liam Wolf, a 19-year-old Australian Army recruit, died after collapsing on an obstacle course at Kapooka during the final training exercise. He experienced a sudden unexpected cardiac arrhythmia while climbing a ladd…

emergency medicinecardiologysystemdelay
SAhospital2009-07-30

Coroner's Finding: BRUNT Sidney

65y · Male·acute right subdural haematoma

Sidney Brunt, aged 65, died from an acute right subdural haematoma caused by excessive, unmonitored anticoagulation with warfarin. His general practitioner, Dr A., prescribed warfarin for atrial fibrillation but failed t…

general practiceemergency medicinemedicationcommunicationwarfarin

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