Coronial

29 results for laryngeal mask airway insertion

NSWhospital2023-10-31

Inquest into the death of Adam Fitzpatrick

20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…

…this did not occur for approximately 46 minutes. Staff attempted blind bougie instrumentation and bag-valve-mask ventilation through a displaced tube, causing bilateral tension pneumothoraces. Delays in emergency airway

intensive careanaesthesiadiagnosticproceduralrocuronium
TAShome2023-11-14

Coroner's Finding: de-identified OV

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

…ics arrived within 6 minutes but struggled to visualize and remove the screw due to blood and vomit in the airway. An intensive care paramedic arrived and successfully removed the screw via laryngoscopy with Magill's for…

paediatricsemergency medicineadrenaline
VIChospital2025-09-29

Finding into death of Baby M

0y · Female·Perinatal asphyxia

…s rather than potentially at 1 minute); higher ventilation pressures could have been considered earlier; laryngeal mask airway should be considered after failed intubations; umbilical catheter securement technique requi…

obstetricsneonatologyproceduralcommunicationadrenaline
NSWcommunity2023-11-07

Inquest into the death of AAB

26y · Male·acute cocaine and alcohol toxicity

…rmed the police officers' response was exemplary and appropriate throughout, including seizure management, airway positioning, and timely resuscitation. The death was not preventable—it resulted from acute toxicity from …

emergency medicinetoxicologycocaine
WAhospital2003-08

Inquest into the Death of Richard Christopher Jankowski

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

…ppeared to recover well in the recovery room. However, approximately 2 hours post-operatively, progressive airway swelling developed rapidly, causing complete obstruction. The initial re-intubation attempt was oesophagea…

anaesthesiageneral surgeryproceduralcommunicationpropofol
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
NSWcommunity2026-03-25

Inquest into the death of Jesse Riley

31y · Male·Status epilepsy secondary to cerebral cavernoma

…expert commentary that earlier monitoring equipment application, earlier lateral repositioning, and closer airway assessment could have been beneficial. No clinical errors were identified as causative, though positioning…

paramedicineemergency medicinecommunicationsystemdroperidol
QLDhospital2008-11-28

McVey, Oliver Steven

67y · Male·Complicated endotracheal tube insertion due to or as a consequence of recent clo…

…remature twin born at 31 weeks gestation weighing 1036g, died from complications of endotracheal tube re-insertion at 67 days of age. Following successful surgical ligation of a patent ductus arteriosus (PDA), Oliver de…

neonatologycardiothoracic surgeryproceduralcommunication
WAhospital2007-06-08

Inquest into the Death of Rasmussen

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

…thesia and paralysis. Subsequent attempts by multiple senior anaesthetists and the surgeon to establish an airway all failed; the trachea was deviated and could not be located. Resuscitation was unsuccessful. The coroner…

anaesthesiageneral surgerydiagnosticproceduralatracurium
VIC2020-12-09

Finding into death of Alma Lynette Honeychurch

76y · Female·Ludwig's angina

… arrangements made for transfer to a tertiary centre. However, staff failed to recognise the risk of rapid airway compromise despite documented clinical deterioration (increased noise in breathing, worsening swelling, di…

emergency medicinedentistrydiagnosticcommunicationantibiotics
VIChospital2020-03-18

Finding into death of Sommer Bethany Warren

18y · Female·Generalised tonic-clonic seizure and cardiac arrest arising from severe hyperten…

An 18-year-old pregnant woman presented in labour at 41 weeks and 2 days gestation. From 23 September onwards, she experienced intermittent headaches, epigastric pain, proteinuria and peripheral oedema. At 1755 hours on …

obstetricsanaesthesiamedicationdiagnosticropivacaine
WAhome

Inquest into the death of Nicole Emily BICKNELL

18y · Female·Acute Alcohol Toxicity with Early Pneumonia and Aspiration

…s from alcohol intoxication is a medical emergency requiring immediate hospital admission and professional airway management. Those present lacked understanding of alcohol toxicity, respiratory depression, and aspiration…

toxicologyemergency medicinedelaysystemalcohol
NSWhospital2018-11-23

BURTON-HO Anqelique File 2015-235464 Findings given by Mag Grahame DSC on 23-11-2018

12y · Female·Cardio-respiratory failure due to aspiration pneumonia

Angelique Burton-Ho, age 12, with VACTERL syndrome and difficult airway, presented to Bowral Hospital ED on 9 August 2015 with respiratory symptoms. She was inadequately triaged …

anaesthesiaemergency medicinediagnosticdelay
QLDhome2019-04-17

Davis, John

50y · Male·Hypoxic-ischaemic encephalopathy secondary to choking on food bolus

… dispatcher delayed recognition of cardiac arrest. Paramedics initially failed to visualise and remove the airway obstruction due to inexperience with laryngoscopy and faulty equipment; a critical care paramedic removed …

emergency medicineparamedicinediagnosticcommunicationmidazolam
VIC2021-02-24

Finding into death of Mark Capovilla

39y · Male·Choking on a food bolus

Mark Capovilla, a 39-year-old man with severe intellectual disability, epilepsy, and dysphagia, died from choking on food at his day program. He had a documented choking risk but lacked a current mealtime support plan at…

general practiceforensic medicinecommunicationsystem
NSWpolice custody2024-06-25

Inquest into the death of Brett Furner

54y · Male·acute myocardial infarction due to coronary artery atherosclerotic disease

Brett Furner, a 54-year-old man with significant coronary artery disease and recent myocardial infarction (February 2023), suffered an acute myocardial infarction and cardiac arrest while in police custody at Goulburn po…

cardiologyemergency medicinediazepam
NSWcommunity2020-10-30

COOK Grant Findings

28y · Male·Hypoxic brain injury as a result of a respiratory arrest, after inadequate respi…

Grant Cook, aged 28, collapsed during a rugby league game after a tackle caused him to fall and hit his head. He suffered a grand mal seizure with snoring/obstructed breathing, leading to respiratory arrest, cardiac arre…

paramedicineintensive carecommunicationdiagnosticadrenaline
VIChospital2026-01-23

Finding into death of Trang Thi Thu Le

28y · Female·3,4-methylenedioxy-N-methylamphetamine (MDMA) and ketamine toxicity

Trang Thi Thu Le, 28, died on her birthday from MDMA and ketamine toxicity after attending an electronic dance music event at John Cain Arena. She collapsed after consuming drugs purchased from an unknown source within t…

emergency medicineintensive caresystemMDMA
WAcommunity2019-06-26

Inquest into the Death of Frederick John COLLARD

35y · Male·atherosclerotic heart disease with methylamphetamine effect in a man under physi…

A 35-year-old male with severe pre-existing ischaemic heart disease and recent cardiac arrest (April 2016) presented with increasingly erratic and paranoid behaviour after methylamphetamine use and alcohol consumption. H…

cardiologyemergency medicinemethamphetamine
NSW2016-11-04

Inquest into the death of Phillip Hughes

25y · Male·traumatic basal subarachnoid haemorrhage due to vertebral artery dissection

Phillip Hughes, a 25-year-old professional cricketer, died from traumatic basal subarachnoid haemorrhage caused by vertebral artery dissection after being struck on the neck by a cricket ball during a Sheffield Shield ma…

emergency medicineneurosurgerycommunicationsystem

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.