Coronial

57 results for intubation attempt

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 urgent re-intuba…

intensive careanaesthesiaproceduralcommunicationpropofol
VIChospital2023-07-31

Finding into death of Michael Stankic

29y · Male·Pulmonary thromboembolism secondary to deep venous thrombosis

…r-old man died from pulmonary thromboembolism secondary to deep vein thrombosis (DVT) following a suicide attempt by hanging. He was admitted to ICU and appropriately commenced on prophylactic enoxaparin 40mg daily. On …

intensive carepsychiatrysystemdelayenoxaparin
SAhospital2006-01-12

Coroner's Finding: EVANS Shaun Michael

22y · Male·Mixed Diflunisal and Buproprion (Zyban) toxicity

…ide Hospital's Emergency Department after taking approximately 110 Zyban (bupropion) tablets as a suicide attempt. Unknown to treating staff, he had also ingested a potentially lethal quantity of diflunisal (an anti-inf…

emergency medicinetoxicologydiagnosticcommunicationbupropion
SAhospital2006-10-30

Coroner's Finding: GORDON Sally Anne

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 …

emergency medicineanaesthesiamedicationproceduralsalbutamol
VIChospital2020-10-19

Finding into death of BABY FF

2y · Male·Hypoxic ischaemic encephalopathy and intracranial haemorrhage complicating obstr…

…erienced prolonged labour with foetal tachycardia and reduced variability on CTG monitoring. After failed attempts at vacuum and forceps delivery in the birthing room, an urgent category-one caesarean section was perfor…

obstetricsneonatologymonitoringcommunicationoxytocin
WAhospital2003-08

Inquest into the Death of Richard Christopher Jankowski

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

…operatively, progressive airway swelling developed rapidly, causing complete obstruction. The initial re-intubation attempt was oesophageal rather than tracheal, a critical error not immediately recognised due to apparen…

anaesthesiageneral surgeryproceduralcommunicationpropofol
VIChospital2017-07-18

Finding into death of Lynsie Maree Everett

36y · Female·Complications of pneumonia and pulmonary emphysema with bullae formation; respir…

A 36-year-old woman with congenital chest wall abnormality, scoliosis, and difficult intubation history presented to a rural hospital with community-acquired pneumonia and sepsis. She had multiple 're…

emergency medicineinfectious diseasesdiagnosticsystemsalbutamol
VIChospital2022-12-16

Finding into death of Arthur Peter Andrianakis

51y · Male·Hyperthermia of unknown cause in a man with cardiac hypertrophy; chronic obstruc…

Arthur Andrianakis, 51, died from hyperthermia of unknown cause with cardiac hypertrophy and COPD. He presented to hospital with respiratory distress following police custody for assaulting his mother. Initial diagnosis …

emergency medicineintensive caresalbutamol
SAhospital2013-09-03

Coroner's Finding: MUMFORD Michael John

41y · Male·multi-organ failure due to severe lactic acidosis due to metformin toxicity

… and substance abuse history deliberately ingested 390 metformin tablets on 24 December 2009 in a suicide attempt. He presented to the ED conscious and coherent, reporting the overdose. He was admitted to ICU where dial…

intensive careemergency medicinemetformin
TAShome2023-11-14

Coroner's Finding: de-identified OV

1y · Male·hypoxic brain damage due to laryngeal obstruction from foreign body (metal screw…

An 11-month-old boy died from hypoxic brain damage following aspiration of a 2cm metal screw that lodged in his larynx. The child was left briefly unsupervised at home when he ingested the screw and began choking. Parent…

paediatricsemergency medicineadrenaline
VIChospital2017-12-07

Finding into death of Waisele Qalubau

39y · Male·Complications of large bowel pseudo-obstruction

…emas on 2 February 2017. He collapsed with faecal vomiting, aspiration, and bowel obstruction, requiring intubation and ICU care. Despite aggressive management including colonoscopy and laparotomy, he deteriorated from i…

psychiatrygastroenterologyclozapine
VIChospital2026-02-05

Finding into death of Max Peter McKenzie

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…

emergency medicineparamedicinedelaycommunicationadrenaline
SAhospital2020-01-10

Coroner's Finding: FIORETTI Louisa Jill Josephine

19y · Female·2,4-dinitrophenol toxicity

…h an Inpatient Treatment Order in place. Despite expert multidisciplinary management including sedation, intubation, ECMO, attempted dialysis, charcoal administration, and dantrolene use, she deteriorated rapidly with un…

toxicologyemergency medicine2,4-dinitrophenol
VIChospital2014-09-11

Finding into death of Daniel Raymond Cowan

15y · Male·global hypoxic cerebral injury following medical intervention for high velocity …

…ing neurosurgery, the injury was devastating. He initially survived with Glasgow Coma Scale 9, underwent intubation, surgery, and decompressive craniectomy. However, he developed staphylococcal meningitis, severe cerebra…

neurosurgeryintensive caremidazolam
SAhospital2015-03-06

Coroner's Finding: SIMOS Theodoras Joannas

48y · Male·undetermined

A 48-year-old man with schizoaffective disorder, poorly controlled diabetes, sleep apnoea, obesity and cardiomegaly died unexpectedly at a rural hospital following acute psychotic agitation. He had absconded from a menta…

psychiatrygeneral practicesystemdelayhaloperidol
VIChospital2009-12-22

Finding into death of Jodi Joy McPaul

33y · Female·Hypoxic brain injury secondary to plastic bag asphyxia

…n Hospital on 29 March 2007. Despite psychiatric team awareness of her vulnerability and previous suicide attempt, she died on 1 May 2007 from asphyxiation using a plastic bag secured with knitting wool in a hospital to…

psychiatryintensive careolanzapine
VIC2019-12-05

Finding into death of Serafina Pirrottina

57y · Female·Complications of muscular dystrophy

A 57-year-old woman with longstanding muscular dystrophy and newly diagnosed cardiomyopathy died from complications of her underlying condition. She became acutely unwell overnight at her residential support facility wit…

respiratory medicineemergency medicinerosuvastatin
VIChospital2025-02-20

Finding into death of Mia Rose Iskander

0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the sett…

…(3:31 pm) due to waiting for blood results and fasting confirmation, and a junior doctor was permitted to attempt spinal anaesthesia during an obstetric emergency. Escalation failures and inadequate senior involvement c…

obstetricsneonatologydiagnosticdelayamoxicillin
VIChospital2025-07-14

Finding into death of Baby Sidney

0y · Male·Head injury sustained in a difficult delivery including head impaction and caesa…

…from severe hypoxic-ischaemic encephalopathy caused by head impaction during a difficult vaginal delivery attempt and subsequent caesarean section at 6 days old. The coroner found that medical care fell short of accepta…

obstetricsneonatologydiagnosticcommunicationoxytocin
SAhome2025-03-31

Coroner's Finding: Constantine, Matthew Keith

33y · Male·hypoxic-ischaemic encephalopathy due to hanging with resuscitation

Matthew Keith Constantine, aged 33, died from hypoxic-ischaemic encephalopathy following a hanging attempt while under home detention. He was released from prison in December 2021 with parole conditions including…

intensive careemergency medicinemethamphetamine

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