Coronial

690 results for emergency intubation

VIChospital2012-07-16

Finding into death of Ruben Chand

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

Ruben Chand, a 42-year-old male, suffered a fatal hypoxic brain injury during emergency re-intubation in ICU. After an initially reasonable extubation decision, he deteriorated and required ur…

intensive careanaesthesiaproceduralcommunicationpropofol
ACThospital2014-03-03

Findings Into The Death Of Sukanya Thurairajah

56y · Female·hypoxic ischaemic encephalopathy due to inadvertent oesophageal intubation and f…

…y 2011. She had an adverse reaction characterised by vomiting, breathlessness and hypertension. MET team intubation was performed by first-year anaesthetic registrar Dr T., who had never previously performed emergency in…

anaesthesiaintensive careproceduralcommunicationhydrocortisone
VIChospital2025-02-12

Finding into death of Alexander Cameron

40y · Male·Aspiration pneumonia

…psy, autism, and previous neuroleptic malignant syndrome (NMS), died from aspiration pneumonia following intubation at Werribee Mercy Hospital. He presented with acute abdominal pain and vomiting, imaging suggested small…

intensive caregeneral surgeryclozapine
VIChospital2012-10-26

Finding into death of Rodney David Keegan

41y · Male·Cardiomyopathy in a setting of acute abdomen

…ntifiable cause. He suffered cardiopulmonary arrest, was resuscitated and intubated but aspirated during intubation attempts. His condition deteriorated despite ICU care. The coroner found death resulted from cardiomyopa…

cardiologyintensive carewarfarin
WAhospital2007-06-08

Inquest into the Death of Rasmussen

31y · Female·cerebral anoxia following attempted intubation pre-surgery in a woman with torti…

…orticollis, dysmorphia, short rigid neck), died on 17 June 2003 from cerebral anoxia following attempted intubation at Joondalup Health Campus. She was admitted for elective left inguinal hernia repair. Dr L., the anaest…

anaesthesiageneral surgerydiagnosticproceduralatracurium
VIChospital2013-03-15

Finding into death of Rolden Ablis

5y · Male·Brainstem encephalitis (viral)

Rolden Ablis, aged 5, presented to Frankston Hospital Emergency Department with fever, vomiting, and dehydration on 10 December 2007. He was diagnosed with gastroenteri…

paediatricsemergency medicinediagnosticdelayparacetamol
NSW2012-05-15

Grainger ,helen finding 1767 08 2012 05 31 14 40 06 300

29y · Female·Hypoxic Encephalopathy consequent upon Cardiorespiratory Arrest arising from eit…

…ey clinical failures: inadequate monitoring (no ECG, no blood pressure recording during crisis), lack of intubation expertise in the attending clinician (hadn't intubated since 1994), and inappropriate facility choice (d…

general practiceobstetricsproceduralsystemcephalosporin
SAhospital2006-10-30

Coroner's Finding: GORDON Sally Anne

20y · Female·Cerebral anoxia consequent upon a severe acute asthmatic event

…spital on 26 November 2000 with acute severe asthma unresponsive to initial treatment. After appropriate emergency management including oxygen, adrenaline and hydrocortisone, she was transferred to the High Dependency U…

emergency medicineanaesthesiamedicationproceduralsalbutamol
VIChospital2024-08-21

Finding into death of Hayley Michelle Impey

50y · Female·Aspiration pneumonia, with epilepsy with frequent seizures as contributory cause

…neumonia complicated by epilepsy with frequent seizures. She presented with status epilepticus requiring intubation and transfer to a tertiary hospital. She was extubated the following morning, transferred to the ward fo…

emergency medicineintensive careclonazepam
NSWhospital2021-11-19

Inquest into the death of Emiliana OBUSAN

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 clini…

anaesthesiaorthopaedic surgerydiagnosticcommunicationfentanyl
VIChospital2026-02-05

Finding into death of Max Peter McKenzie

15y · Male·Cardiorespiratory arrest of unknown aetiology complicating hypoxic ischaemic enc…

…tered an EpiPen. Ambulance paramedics administered adrenaline but Max deteriorated rapidly. At hospital, emergency physicians delayed intubation for 15 minutes despite critical hypoxia, attempting to stabilise him first…

emergency medicineparamedicinedelaycommunicationadrenaline
ACThospital2019-06-25

Inquest into the death of Jay Alan Paterson

43y · Male·hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic …

…ossession. Mr Paterson was found unconscious on 31 August with toxic levels of oxycodone and clonazepam. Intubation was technically difficult due to anatomical factors and laryngeal calcification; tracheal perforation oc…

general practicepain medicinesystemproceduraloxycodone
NThospital2026-01-09

Inquest into the death of C Guyula

49y · Female·Hypoxia due to complications following incision and drainage of a right buttock …

…e reversal of neuromuscular blockade (Train of Four monitor not calibrated pre-operatively); oesophageal intubation not recognised due to misidentification of an impedance monitor as capnography; delayed detection allowi…

anaesthesiasurgeryproceduralmedicationfentanyl
VIChospital2025-09-29

Finding into death of Baby M

0y · Female·Perinatal asphyxia

…ng labour or antenatally. The neonatal resuscitation encountered multiple technical difficulties: failed intubation by the junior registrar, then successful intubation by the consultant at 15 minutes of life but without …

obstetricsneonatologyproceduralcommunicationadrenaline
QLDhospital2022-07-08

R - Non-inquest findings

0y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…

…diorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pulmonary oedema requiring intubation. During PICU management, multiple opportunities were missed to verify endotracheal tube positioning: con…

anaesthesiaintensive carediagnosticproceduralpropofol
VIChospital2013-11-18

Finding into death of Sean Raymond Adams

51y · Male·Multiorgan failure in a man with corrected congenital coarctation of the aorta a…

…nsuring adequate airway equipment availability on cardiac wards, particularly given documented delays in intubation during the arrest.

cardiologyemergency medicinecommunicationsystemhaloperidol
VIChospital

Finding into death of Vicki Maree Hay

50y · Female·Aspiration pneumonia

…ing two weeks of outpatient GP treatment for lower respiratory tract infection. She aspirated, requiring intubation for airway protection. CT imaging confirmed aspiration. After initial extubation and rapid reintubation,…

intensive careemergency medicine
QLDhospital2005-10-06

Fernandez, Adam Anthony

33y · Male·Aspiration due to alcoholic intoxication; coronary atherosclerosis contributed

…n for aggressive behaviour, he vomited copiously, aspirating semi-solid food that obstructed his airway. Emergency attempts at intubation and surgical airway management were unsuccessful. The coroner found no clinical f…

emergency medicineanaesthesiasedatives
QLDhospital2026-03-31

Inquest into the death of Robyn Ann Beale

78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …

… Critical delays in diagnosis and management followed: the overnight medical officer lacked endotracheal intubation skills and did not escalate promptly to senior specialists; nursing staff with tutorial training on mana…

general surgeryanaesthesiadiagnosticcommunicationoxycodone
SAhospital2006-05-10

Coroner's Finding: SLOAN Adam Edward John

15y · Male·right haemothorax due to lacerations of right lung

… faulty brakes, crashed into a tree after a party at which minors consumed alcohol provided by an adult. Emergency response was appropriate: rescue teams extracted him from severe entrapment within 100 minutes; pre-hosp…

emergency medicinecardiothoracic surgeryalcohol
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