Coronial

34 results for massive transfusion

SAhospital2001-11-08

Coroner's Finding: STEWART Margaret May

77y · Female·multi-organ failure due to massive transfusion-induced coagulopathy following re…

A 77-year-old woman died from multi-organ failure following massive transfusion-induced coagulopathy after a retroperitoneal haemorrhage of unknown origin post-knee replacem…

surgeryvascular surgerycommunicationsystemdalteparin
QLDhospital2026-02-18

Non-inquest findings into the death of Mr C

62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (su…

… intraoperative factors contributed to poor outcomes: late recognition of blood loss, delay in activating massive transfusion protocol, loss of central line preventing vasopressor administration, inadequate team communi…

urologygeneral surgerydiagnosticcommunicationmetaraminol
SAhospital2001-09-04

Coroner's Finding: CHESTER George Spencer

18y · Male·multiple injuries

…m vehicles; the importance of Glasgow Coma Scale assessment and early airway management; recognition that massive transfusion protocols and aggressive resuscitation were required. The coroner found no clinical error in …

emergency medicinetrauma surgery
VIChospital2019-01-24

Finding into death of Bryan Lindsay Cleeman

86y · Male·Complications post laparoscopic cholecystectomy

…r admission. Severe bleeding from hepatic arterial branches required conversion to open surgery, CPR, and massive transfusion. Myocardial infarction occurred intraoperatively in a patient with underlying coronary artery…

general surgeryanaesthesiadelayasasantin
VIChospital2018-10-11

Finding into death of John Richard Connelly

78y · Male·Complications of blood loss from femoral fracture sustained in harness riding in…

A 78-year-old man with ischaemic heart disease on warfarin sustained a compound femoral fracture with massive bleeding after a harness racing accident in a rural location. Despite exemplary prehospital care and time…

emergency medicinetrauma surgerydelaysystemwarfarin
VIChospital2023-06-23

Finding into death of Edis Vytas Brenner

78y · Male·Multiorgan failure consequent upon pulmonary lacerations and haemorrhage sustain…

…ion or chest drain placement. This resulted in severe unexpected bleeding requiring return to theatre and massive transfusion. The subsequent vasoplegia and multiorgan dysfunction could not be reversed despite appropria…

cardiothoracic surgeryintensive caresystem
VIChome2024-02-13

Finding into death of Child K

12y · Male·Injuries sustained in a quad bike incident (driver)

…ling him with the handlebar. Despite immediate first aid, paramedic resuscitation, emergency surgery, and massive transfusion at Goulburn Valley Health, his injuries were unsurvivable. The coroner noted well-documented …

emergency medicinesurgeryfentanyl
VIChospital2016-04-14

Finding into death of Kelly Maree Richards

29y · Female·Exsanguination post tubal ligation procedure

…r, Mrs Richards' condition became irreversible within 30-60 minutes due to uncontrollable haemorrhage and massive coagulopathy. Clinical lessons include: avoiding excessive trochar insertion pressure during laparoscopy;…

general surgerygynaecologyproceduralcommunicationpacked red blood cells
VIChospital2015-04-02

Finding into death of Linda Elizabeth Parker

39y · Female·Hypoxic brain injury secondary to multiple hypovolaemic cardiac arrests from cat…

…athy and uncontrollable bleeding; (3) Earlier hysterectomy would probably have prevented coagulopathy and massive haemorrhage. The coroner highlighted importance of accurate prenatal diagnosis through proper clinical in…

obstetricsanaesthesiadiagnosticdelay
VIChospital2015-10-20

Finding into death of THI DIEP ANH LU

36y · Female·Haemorrhage complicating elective caesarean section (placenta praevia accreta)

Ms. Thi Lu, aged 36, died from massive hemorrhage following caesarean section for placenta praevia with underlying placenta accreta. Although im…

obstetricsanaesthesiadelayprocedural
SAhospital2003-03-12

Coroner's Finding: STOLL Ruth Sophie

71y · Female·massive acute haemolysis leading to severe anaemia and multi-system failure as a…

Ruth Stoll, 71, died from massive acute haemolysis and multi-system failure after receiving incompatible blood transfusions during aortic a…

cardiothoracic surgeryanaesthesiadiagnosticprocedural
VIChospital2026-01-08

Finding into death of Malakai Cross-De Jesus

<1y · Male·Complications following forceps delivery

…l delivery, improve situational awareness in neonatal resuscitation, and develop statewide guidelines for massive transfusion in neonates.

obstetricsneonatologydiagnosticcommunicationbenzylpenicillin
TAShospital2021-11-29

Coroner's Finding: Bennett, Anthony George

77y · Male·shock due to bowel ischaemia following massive blood loss due to bleeding of the…

…ripheral vascular disease, and end-stage kidney disease, died from shock due to bowel ischaemia following massive blood loss from the left internal iliac artery after elective abdominal aortic aneurysm repair. The initi…

vascular surgerycardiology
WAhospital2005-12-09

Inquest into the Death of Laura Marguerite Sinclair

31y · Female·Post-partum Haemorrhage associated with Amniotic Fluid Embolism and Uterine Hypo…

…within hours. Critical clinical opportunities were missed: coagulation studies were not performed despite massive transfusion requirements; Dr I. did not fully appreciate midwives' concerning vital signs when telephoned…

obstetricsanaesthesiadiagnosticcommunicationpethidine
VIChospital2019-09-26

Finding into death of Tangimama Tavai

35y · Female·Unascertained

… was induced on Sunday evening. She experienced a postpartum haemorrhage with cervical trauma requiring transfusion and resuscitation. Clinical management during the acute crisis was appropriate, but systemic issues con…

obstetricsanaesthesiacommunicationsystemoxytocin
QLDhospitalPodcast2008-10-10

Maxfield, Annette

62y · Female·Haemorrhage caused by abdominoperineal excision of the rectum

…n unconventional perineal-first approach that multiple experts considered dangerous and unnecessary. When massive haemorrhage occurred, management was delayed by inadequate preoperative blood work, blood product availab…

colorectal surgeryanaesthesiadiagnosticproceduralsevoflurane
VIChospital2018-03-29

Finding into death of Roy Irvin Dorner

64y · Male·Complications of redo thoracotomy/aortic valve replacement in a man with ischaem…

…e was inadvertently incised despite use of an oscillating saw and careful technique. The patient required massive transfusion, ECMO support, and extended surgery but developed multi-organ failure and died 29 days post-o…

cardiothoracic surgerycardiology
NSWhospital2025-02-28

Inquest into the death of Heather Winchester

75y · Female·multiple organ failure due to severe anaemia secondary to blood loss post electi…

…the surgical and anaesthetic teams held conflicting understandings about whether she would accept blood transfusion—the surgeon believed she refused all blood products based on her consent form and Jehovah's Witness fai…

gynaecologyanaesthesiacommunicationsystem
SAhospital2010-02-04

Coroner's Finding: KRIVITCH Olga

81y · Female·hypovolaemic shock following bleeding from the site of a femoral angiogram

…es included: haemoglobin levels not monitored on 25-26 January despite evidence of bleeding, resulting in massive undetected haemorrhage; over 4-hour delay between identifying haemoglobin of 54 and transfusion; and lack…

vascular surgeryradiologydiagnosticmedicationheparin
NSWcommunity2020-01-24

Into the death of Thomas Redman

18y · Male·Incised wound to right axilla with complete transection of basilic vein, brachia…

…al helicopter en route to John Hunter Hospital. The case presented extraordinary clinical challenges with massive uncontrollable bleeding in a remote location. Key clinical learning points include: (1) the State Retriev…

emergency medicinetrauma surgerycommunicationsystemoxygen

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