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 urgent re-intuba…
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…
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…
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…
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…
Male·Myocardial failure resulting from excessive pulmonary blood flow and consequenti…
… delay in intubating once clinical deterioration became obvious; and use of propofol for sedation during intubation, which may have contributed to myocardial depression. Despite these management issues, the infant's prog…
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…
5y · Male·Brainstem encephalitis (viral)
…ratory distress, hypoxia, and haemoptysis, clinicians failed to recognise the severity of his condition. Intubation was delayed until 3:45am, after which he suffered cardiac arrest and could not be resuscitated. Autopsy …
20y · Female·Cerebral anoxia consequent upon a severe acute asthmatic event
…t including oxygen, adrenaline and hydrocortisone, she was transferred to the High Dependency Unit where intubation became necessary. Dr N., a medical officer with 10-11 years post-graduate experience, chose pancuronium …
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…
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…
15y · Male·Cardiorespiratory arrest of unknown aetiology complicating hypoxic ischaemic enc…
…ramedics administered adrenaline but Max deteriorated rapidly. At hospital, emergency physicians delayed intubation for 15 minutes despite critical hypoxia, attempting to stabilise him first. A surgical airway was eventu…
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…
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…
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 …
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…
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.
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,…
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…
33y · Male·Aspiration due to alcoholic intoxication; coronary atherosclerosis contributed
…iour, 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 failures: police interve…
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