Coronial

20 results for intubation by retrieval team

SAcommunity2006-02-22

Coroner's Finding: SINCLAIR-SPAAN Christopher James

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

…n rural South Australia. He was trapped for over 2 hours before extrication. Although paramedics and the retrieval team provided high-quality resuscitation, the deceased developed irreversible hypovolaemic shock. Key cl…

intensive caretrauma surgerycommunicationsystem
QLDhospital2016-06-03

James, Kesler Lee

5y · Male·Acute bronchopneumonia and diffuse alveolar damage due to acute rheumatic cardit…

…. Early recognition of the critical acuity could have prompted earlier respiratory support and different retrieval arrangements. The case demonstrates how cognitive biases (diagnostic momentum, framing, confirmation bia…

paediatricsintensive carediagnosticcommunicationfurosemide
SAhospital2015-03-06

Coroner's Finding: SIMOS Theodoras Joannas

48y · Male·undetermined

…hospitals managing acutely psychotic patients face significant complexity; early transfer via specialist retrieval (not RFDS/ambulance) may be preferable; careful medication choice considering respiratory sensitivity is…

psychiatrygeneral practicesystemdelayhaloperidol
QLDhospital2020-08-26

Baby C - non-inquest findings

0y · Male·meconium aspiration syndrome complicated by persistent pulmonary hypertension

…nsville Hospital NETS until 9 hours of age when early contact (within 2 hours) would have enabled timely retrieval and nitric oxide therapy; (5) NETS arrival delayed by 5+ hours due to aircraft unavailability. Baby C de…

neonatologyobstetricsdiagnosticproceduralmorphine
VIChospital2023-10-20

Finding into death of Vanessa Li

0y · Female·subgaleal haematoma complicating an obstructed labour

…diatrician, documented concern about possible SGH but did not clearly communicate this risk to the PIPER retrieval team during handover. The SGH was not identified until 7.30am, approximately 6 hours after birth. Earlie…

obstetricsneonatologycommunicationdiagnosticoxytocin
QLDhospital2018-07-30

Khazaei, Hamid

24y · Male·Hypoxic-ischaemic encephalopathy, due to or as a consequence of cardiac arrest, …

…e and aggressively resuscitate him before transfer; inadequate handovers and communication between clinical teams; delayed transfer approval due to bureaucratic processes; and inadequate critical care capacity at the rec…

emergency medicineinfectious diseasesdiagnosticcommunicationceftriaxone
SAhospital2013-02-08

Coroner's Finding: FENSOM Angela Catherine and TAANKINK Johaanes Andrew

Unknown·Ms Fensom: influenza A (H1N1 2009, pandemic swine flu) with myocarditis causing …

…neumonia development might have been prevented. After admission on 10 August with pneumonia, he required intubation and mechanical ventilation by 11 August evening (24 hours earlier than it occurred), with prompt retriev…

emergency medicinegeneral practicediagnosticcommunicationoseltamivir
VIChospital2022-04-28

Finding into death of Hunter Patrick Boyle

2y · Male·Consistent with drowning

…ght of the child, the grandfather found Hunter floating face-down in a small dam. Despite immediate CPR, retrieval by paramedics, and extensive resuscitation attempts at hospital including hypothermia management and PIP…

emergency medicinepaediatricsmorphine
QLDhospital2018-05-04

LM - Non-inquest findings

1y · Female·Sepsis (Group A Streptococcus)

…hock, delayed intravenous access (three hours), delayed antibiotics and fluid resuscitation, and delayed retrieval initiation. The child deteriorated acutely with petechial haemorrhages and shock, ultimately developing …

general practiceemergency medicinediagnosticdelaymupirocin
NSWhospital2022-12-08

Inquest into the death of Austin Facer

6y · Male·cardiopulmonary arrest on a background of earlier cardiac arrests and resuscitat…

…icular fibrillation and immediate escalation to transfer planning; and (3) the need for clear interstate retrieval protocols between NSW and South Australia. The coroner found the medical treatment Austin received was a…

paediatricsemergency medicinecommunicationsystemadrenaline
VIChospital2025-08-13

Finding into death of Jordan Thomas Alexander McDonald

0y · Male·complications of extreme prematurity in the setting of precipitant premature bre…

…t was administered 10 times the prescribed morphine dose due to calculation error during a time-critical retrieval scenario. Although this was a serious medication error, the expert evidence concluded the morphine was u…

neonatologyobstetricsmedicationdiagnosticmorphine
SA2018-01-30

Coroner's Finding: JONES Heath Ryan

35y · Male·hypoxic-ischaemic encephalopathy (post cardiac arrest) on a background of acute …

A 35-year-old man died by hanging in a medium-security prison while on remand. He was found unresponsive in his cell with a ligature around his neck. Despite immediate CPR, transfer to hospital and transfer to ICU at Fli…

emergency medicineintensive caresystemmethamphetamine
TAShospital2024-03-27

Coroner's Finding: Leary, Kane

17y · Male·stroke (left middle cerebral artery infarction) following motorbike collision du…

…irreversible brain damage occurred. Had the dissection been detected within 6-8 hours, endovascular clot retrieval could have offered salvage. Key failures: (1) radiologist interpretation error on original scans; (2) ab…

emergency medicineneurosurgerydiagnosticcommunicationmorphine
SAhospital2001-09-04

Coroner's Finding: CHESTER George Spencer

18y · Male·multiple injuries

George Spencer Chester, 18, died from multiple injuries sustained when a stolen Toyota 4WD he was driving rolled on Decres Bay Road after failing to negotiate a bend while being pursued by police. He was ejected from the…

emergency medicinetrauma surgery
VIChospital2020-05-21

Finding into death of Baby S

Female·Sepsis in the setting of a lotus birth

…unting, pallor, and hypothermia; antibiotics were started promptly. Despite aggressive resuscitation and retrieval to a tertiary centre, she died from sepsis with evidence of early necrotising enterocolitis and umbilica…

obstetricspaediatricscommunicationsystembenzylpenicillin
VIChospital2015-06-12

Finding into death of Baby Chloe Lee Kellett

5y · Female·Cerebral hypoxic and ischaemic injury in a setting of clinical birth asphyxia

Chloe Kellett was born at 39 weeks gestation after induction of labour for rupture of membranes and group B streptococcus positivity. She was delivered by forceps in theatre for a non-reassuring cardiotocogram (CTG) trac…

obstetricspaediatricsdiagnosticcommunicationoxytocin
VIChospital2024-12-02

Finding into death of Baby Patel

0y · Unknown·unascertained

…e paediatric assessment. The infant was subsequently managed appropriately with antibiotics, fluids, and retrieval but deteriorated despite intensive care including intubation and ECMO support. Cause of death was unasce…

neonatologypaediatricsdiagnosticcommunicationcefotaxime
NSWcommunity2019-10-04

Inquest into the death of Olivia INGLIS

27y · Female·chest injuries

Olivia Inglis, 27, died from chest injuries sustained in a fall whilst competing in the cross country phase of eventing at the 2016 Scone Horse Trials. She successfully negotiated fence 8A but fell at fence 8B. The coron…

emergency medicineparamedicinesystemcommunication
QLDhospitalPodcast2011-10-07

Saunders, Ryan Charles

2y · Male·Group A Streptococcal toxic shock syndrome which probably originated in the thro…

Ryan Saunders, a 2-year-old boy, died from Group A Streptococcal toxic shock syndrome after a 72-hour presentation with fever, pain, and systemic illness. Initial GP care was appropriate given the presentation and diagno…

paediatricsemergency medicinediagnosticcommunicationparacetamol
VICcommunity2013-10-21

Attachment a

Blunt force trauma sustained in level crossing collisions between heavy vehicles…

Coronial investigation into 26 deaths at 12 level crossing incidents in Victoria between 2002-2009, with focus on the Kerang incident (5 June 2007) where 11 train passengers died after a semi-trailer collided with a pass…

emergency medicineparamedicinediagnosticcommunication

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