Coronial

16 results for massive transfusion protocol

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
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
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
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

0y · Male·Complications following forceps delivery

…ck. Key preventive measures: transfer to theatre when red flags appear, implement robust scalp monitoring protocols post-instrumental delivery, improve situational awareness in neonatal resuscitation, and develop statewi…

obstetricsneonatologydiagnosticcommunicationbenzylpenicillin
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
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
SAcommunity2006-02-22

Coroner's Finding: SINCLAIR-SPAAN Christopher James

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

A 21-year-old man died from massive internal bleeding into the pelvis and retroperitoneum following a motor vehicle collision with a stobie p…

intensive caretrauma surgerycommunicationsystem
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
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
VIChome2021-12-21

Finding into death of Geoffrey Alan Locks

50y · Male·Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (t…

…o delay occurred once ambulance was appropriately requested, earlier activation or streamlined non-verbal protocols might have expedited response. Hospital discharge care was appropriate; death was likely not preventable…

ENT surgeryoncologysystemcommunicationmethadone
NThospital2011-09-09

Inquest into the death of Linda Nha Tran

34y · Female·Catastrophic post-partum haemorrhage following caesarean delivery, secondary to …

…an elective caesarean delivery. Placenta accreta was discovered intraoperatively and managed with blood transfusion, uterotonic agents, and a Bakri balloon. Dr L. administered prostaglandin F2α at an excessive dose (3mg…

obstetricsanaesthesiamedicationcommunicationoxytocin
WAhospital2009-02-01

Inquest into the Death of Fox

62y · Male·Acute Gastrointestinal Haemorrhage in association with Acute on Chronic Peptic U…

…mantle Hospital ED on 12 April 2006 with a gastrointestinal bleed after fainting. He was diagnosed with a massive bleed causing hypovolaemic shock and stabilized with fluid resuscitation. However, due to difficulty dete…

emergency medicinegeneral surgerydiagnosticdelayaspirin
QLDhospital2018-10-24

Statis, Joshua Ryan

12y · Male·Cardiac haemorrhage due to or as a consequence of congenital aortic stenosis (su…

Joshua Statis, a 12-year-old with complex congenital aortic stenosis, died 18 days after a redo Konno procedure and aortic valve replacement when a CardioCel patch to the right ventricular outflow tract (RVOT) ruptured, …

cardiothoracic surgerycardiologycommunicationdiagnosticwarfarin

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