Coronial

25 results for low blood pressure (hypotension)

TAShospital2024-10-10

Coroner's Finding: Hill, James Fredrick

74y · Male·small intestinal ischaemia caused by aortic atherosclerosis

A 74-year-old man presented to hospital with abdominal pain following a fall. He developed hypotension, fever, tachycardia, and elevated inflammatory markers consistent with …

emergency medicineorthopaedic surgerydiagnosticcommunication
NSWhospital2015-12-02

Inquest into the death of Jessica Martin

24y · Female·peri-myocarditis in the presence of sub clinical Addison's disease

…2009 and was diagnosed with viral pleurisy without specific investigations for Addison's disease. While her low-normal blood pressure and significant weight loss were features of Addison's, the expert found these were a…

emergency medicineradiation oncologydiagnosticneurofen
NSWhospital2015-03-16

Inquest into the death of John Gibson

63y · Male·Right cerebral infarction caused by infusion of medication via central venous li…

…sed via the arterial line, causing right cerebral infarction. The clinician relied on absence of pulsatile flow and blood colour to confirm placement but failed to perform manometry, transduction, or blood gas assessmen…

surgeryanaesthesiaproceduraldiagnosticdiazepam
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 …

…orning on 18 August, but the treating registrar (Dr V.) failed to recognise the seriousness of persistently low blood pressure despite it not responding to fluid therapy. Mr Taankink (26), an asthmatic, was prescribed T…

emergency medicinegeneral practicediagnosticcommunicationoseltamivir
SAhospital2006-05-19

Coroner's Finding: FALANGA Salvatore

77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…

77-year-old male died from complications of haemothorax and hypotension following drainage of pleural effusion post-coronary bypass surgery, in the setting of pre-existing renal impairme…

cardiologycardiothoracic surgerydiagnosticproceduralramipril
VIChospital2014-03-21

Finding into death of Michelle Johnson

31y · Female·Ruptured splenic artery aneurysm with extensive retroperitoneal and intraperiton…

…potension on 21 March 2010. She was assessed by registrar Dr F. and covering specialist Dr L., with initial low blood pressure attributed to musculoskeletal pain from dancing. Investigations were unremarkable. After dis…

obstetricsemergency medicinecommunicationsystempethidine
VIChospital2023-10-06

Finding into death of G A

86y · Female·Bradycardic arrest secondary to relative hypoperfusion while undergoing surgery …

An 86-year-old woman underwent elective surgery to excise a probable squamous cell carcinoma from her left hand with split-thickness skin grafting under local anaesthesia with intravenous sedation. She suffered an unexpe…

dermatologyplastic and reconstructive surgerymedicationpropofol
SAhospital2008-08-22

Coroner's Finding: CARTER Kenneth Morton

76y · Male·ruptured abdominal aortic aneurysm

…nstellation of symptoms and prior AAA history. A CT scan would likely have been diagnostic and might have allowed intervention, though prognosis would have been poor given Mr Carter's comorbidities.

emergency medicinegeneral medicinediagnosticsystemwarfarin
SAhospital2020-11-03

Coroner's Finding: WHISKEY Louise Kitty

51y · Female·community acquired pneumonia

…eatment, an Acomed infusion pump failed silently, temporarily compromising noradrenaline delivery when her blood pressure was critically low (60 mmHg systolic). Despite manual administration resumption and maximal vasop…

intensive carepsychiatrysystemnoradrenaline
VIChospital2014-02-26

Finding into death of Dean Lovett

21y · Male·dilated cardiomyopathy

…ptember 2008. Dr G. identified clinical signs concerning for cardiac disease (tachycardia, finger clubbing, low blood pressure) but delayed investigations until Monday. Dean deteriorated and attended ED on 7 September, …

emergency medicinegeneral practicediagnosticdelaymethotrexate
NSWcommunity2017-08-21

Inquest into the death of Samuel SEETO

29y · Male·Florid myocarditis

…. Key clinical lessons: syncope is concerning and mandates cardiac evaluation; young patients with fatigue, low blood pressure, and syncope require careful differential diagnosis including cardiac causes; chest ausculta…

general practicecardiologydiagnosticcommunicationibuprofen
NSWhospital2022-08-17

Inquest into the death of Robert Bischard

75y · Male·multifactorial causes on a background of ischaemic heart disease, generalised va…

…s: absent pre-operative physician-led assessment despite high-risk profile; failure to recognise critically low urine output (3ml) post-operatively despite protocols; poor fluid balance charting and medication managemen…

orthopaedic surgerycardiologydiagnosticsystemfurosemide
NSWhospital2024-04-12

Inquest into the death of Everett Carleton

0y · Male·multifactorial with severe hypoxia/hypotension which occurred in the background …

Everett Carleton died at birth following an emergency caesarean section complicated by unexpected placenta praevia and umbilical cord transection…

obstetricsneonatologycommunicationprocedural
QLDcommunity2016-12-08

Floyd, Leah Elizabeth

48y · Female·Sepsis due to pulmonary and cutaneous infections, with urinary tract infection a…

A 48-year-old tetraplegic woman died from sepsis originating from a necrotic sacral pressure wound. Multiple system failures contributed: inadequate pressure sore prevention at the disability care p…

neurologypsychiatrycommunicationsystemdiazepam
WAhospital2010-03-03

Inquest into the Death of McLevie

38y · Female·Streptococcus Group A Septicaemia (Post Partum-Puerperal Sepsis)

…year-old woman, died on 6 April 2006 from untreated Group A Streptococcal septicaemia (puerperal sepsis) following childbirth at Osborne Park Hospital. She developed fever (38°C) at 3am on 5 April, only three hours afte…

obstetricsmidwiferydiagnosticcommunicationparacetamol/codeine
VIChospital2014-11-28

Finding into death of June Olive Pegg

80y · Female·peritonitis due to sigmoid resection margin leak following extended right hemico…

June Olive Pegg, 80, died from peritonitis following anastomotic leak after extended right hemicolectomy for colonic cancer. Critical delays in diagnosis occ…

colorectal surgerygeneral surgerydiagnosticdelayfurosemide
QLDhospital2015-08-28

Wright, Verris Dawn; Carter, Jasmyn Louise

Female·Verris Dawn Wright: septic shock due to small bowel ischaemia secondary to small…

…sing clinical deterioration in rural hospital patients. Mrs Wright, 86, presented with abdominal pain and a low temperature (early sepsis), but staff did not escalate when she deteriorated over four hours. No doctor rev…

emergency medicinegeneral practicediagnosticcommunication
SAhospital2004-11-18

Coroner's Finding: PEDDEY Ross Dudley

63y · Male·pneumonia complicating anoxic brain injury, due to post-operative haemorrhage as…

A 63-year-old man died from pneumonia complicating anoxic brain injury following a post-operative haemorrhage from the inferior epigastric artery during ileostomy closure surgery. The c…

colorectal surgerygeneral surgerydiagnosticdelaywarfarin
QLDhospital2017-07-31

Mrs NSM - Non-inquest findings

81y · Female·left haemothorax and mediastinal haemorrhage from the insertion site of the perm…

An 81-year-old woman died from haemothorax and mediastinal haemorrhage following pacemaker insertion for sick sinus syndrome. Multiple venous punctures during the procedure caused vascu…

cardiologyintensive carediagnosticcommunicationglyceryl trinitrate
VIChospital2015-07-01

Finding into death of Robert Charles Avery

86y · Male·Septic shock secondary to urosepsis

…ith fluid restriction, bowel preparation, and insulin adjustment. Despite overnight clinical deterioration (low blood pressure, rectal bleeding, poor oral intake), he was discharged on day 2. An emergency physician revi…

surgerygastroenterologycommunicationsystemmixtard insulin

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