Coronial

304 results for multi-system failure

ACT2018-11-01

AN INQUIRY INTO THE FIRE AT THE SYDNEY BUILDING

Fire caused by unattended cooking wok on gas stove with ignited cooking oil

A fire occurred at Sydney Building, Canberra City on 17 February 2014 in the kitchen of Japanese restaurant Izakaya Coo 2 G 4 U, caused by an unattended cooking wok on a gas stove that ignited cooking oil. A staff member…

systemdelay
VIChospital2025-02-13

Finding into death of Jack Brownlee

21y · Male·Complications of injuries sustained when a trench wall collapsed

… was essential and appropriately deployed. Crush syndrome with acute compartment syndrome and multi-organ failure proved fatal. The coroner determined his death was preventable, attributing it to Pipecon's failure to pr…

emergency medicinetrauma surgerysystemmidazolam
VIChospital2014-08-27

Finding into death of Robert Vivian Hawkins

55y · Male·Multi-system failure complicating intra-operative haemorrhage due to inadvertent…

Robert Vivian Hawkins, a 55-year-old man, died from multi-system failure following inadvertent ligation of the superior mesenteric artery (SMA) during laparoscopic neph…

urologygeneral surgerydiagnosticprocedural
VIChospital2025-06-25

Finding into death of RFV

87y · Male·Consequences of an assault with severe facial fractures

…and subsequently developed large cerebral infarcts. Despite resuscitation and ICU management, multi-organ failure and devastating stroke made neurological recovery unlikely. The coroner found the death resulted from cri…

emergency medicineintensive caresystem
NThospital2018-06-19

Inquest into the death of Naomi Smith

26y · Female·Pulmonary embolism as a consequence of dislodged deep vein thrombosis

…l health needs (BPD, PTSD, depression) and morbid obesity. The critical clinical lessons centre on system failure rather than individual error. Alice Springs lacked forensic mental health expertise and resources to mana…

psychiatryintensive caresystemdelay
NSWhospital2010-07-22

Finding helanisirianni257 08 dscmitchell

Female·Hypoxic ischaemic encephalopathy following hypovolaemic shock and multi-organ fa…

…ni Sirianni, born 8 February 2008, died less than 3 days later from subgaleal haemorrhage and multi-organ failure. She was delivered by vacuum extraction after labour complicated by fetal distress. The vacuum extraction…

obstetricsmidwiferydiagnosticcommunication
VIChospital2011-08-23

Finding into death of Roderick Allen

48y · Male·Decompensated liver and renal disease; alcoholic liver disease in the circumstan…

…l-thickness burns and inhalation injury. His pre-existing severe liver disease and subsequent multi-organ failure were the primary causes of death. The coroner found the fire was likely caused by a discarded cigarette i…

forensic medicineemergency medicine
NSW2015-08-14

Inquest into the death of Andrew Alan Thomas WILSON

27y · Male·Effects of fire and inhalation of products of combustion sustained when the airc…

A 27-year-old pilot died when the aircraft he was piloting experienced engine failure during cruise, resulting in impact with the ground and fire. The death was caused by effects of fire and …

system
VIChospital2010-12-01

Finding into death of Leonie Bedggood

Female·Hypovolaemic shock secondary to multi-trauma resulting from a motor vehicle acci…

…sed by an unattached fruit bin trailer. A trailer became detached from a towing vehicle due to mechanical failure of the coupling system and collided head-on with Ms Bedggood's vehicle. The coroner identified that the d…

QLDcommunity2022-06-29

Clarke, Hannah Ashlie; Baxter, Aaliyah Anne; Baxter, Laianah Grace; Baxter, Trey Rowan Charles; Baxter, Rowan Charles

Mixed·Hannah Clarke: multi-organ failure due to effects of fire; Aaliyah, Laianah and …

…tic violence and coercive control throughout the relationship. Significant missed opportunities included: failure to pursue criminal charges for strangulation and sexual assault; inadequate police training in domestic v…

emergency medicineparamedicinediagnosticcommunication
QLDhospital2009-02-09

Clarke, Jon Edward Norman

22y · Male·multi-organ failure secondary to heatstroke

…XR, collapsed from heatstroke while working as a trolley boy on 27 January 2007 and died from multi-organ failure on 8 February 2007. He was employed through STEPS Employment and appropriately advised about hydration an…

psychiatryintensive caresystemdelayclozapine
VIChospital2022-02-22

Finding into death of Matthew Lee Dongelmans

30y · Male·Complications of methylamphetamine toxicity

…the delay likely did not prevent death, as the acute methylamphetamine toxicity and resulting multi-organ failure would have been difficult to reverse regardless. Police response was timely and appropriate. Hospital imp…

emergency medicineintensive caredelaysystemmethamphetamine
NT2014-10-14

Inquest into the death of Richard Baird

8y · Male·hypoxic brain injury and multi-organ failure from drowning

…bated and ventilated but remained deeply unresponsive, and died from hypoxic brain injury and multi-organ failure on 20 January. The coroner found that the drain grates were inadequately secured (bolts were missing or i…

intensive careemergency medicinesystemdelay
QLD2011-09-29

Tiers, Matthew Maurice

53y · Male·Multi-organ failure due to sepsis

…ectional Centre. He developed sepsis from an acute infection (likely pneumonia) and died from multi-organ failure at Rockhampton Hospital. Clinical lessons include: initial medical assessment at prison reception was per…

intensive careemergency medicinediagnosticsystemdiazepam
QLDhospital2007-12-20

Newman, Patricia Dell

72y · Female·Congestive cardiac failure due to or as a consequence of essential hypertension

…ged 72, was admitted to Rockhampton Base Hospital on 11 March 2006 with profound hypotension, acute renal failure, severe malnutrition, and multi-organ failure that had developed over weeks to months. Her presentation m…

general medicinerespiratory medicinecommunication
NSWmental health2011-09-02

Ang 2011 09 21 13 31 50 906

29y · Male·acute bronchopneumonia complicated by multi-drug toxicity

…ic levels of codeine and morphine, exacerbated by CYP2D6 polymorphism affecting drug metabolism. Critical failures: RMO not consulting psychiatrist before prescribing medication; inadequate close observation procedures;…

psychiatrygeneral medicinemedicationcommunicationclozapine
QLD2007-03-21

Davis, Shane William

29y · Male·Multiple injuries from being struck by a tyre and rim assembly when attempting t…

…n mining-specific hazards for transport workers, and effective contractor safety management. Contributory failures included inadequate safety procedures, insufficient worker training on stored energy hazards, lack of ri…

occupational and environmental healthemergency medicinesystemcommunication
QLDhospital2015-07-08

Hamilton, Michael John - Non-inquest findings

72y · Male·Multiple organ failure due to sepsis caused by abdominal adhesions from previous…

…er accepted that complex presentation justified initial management and that ultimate outcome (multi-organ failure from severe pancreatitis and subsequent sepsis from adhesions) would likely have occurred regardless. The…

surgeryintensive carediagnosticsystemwarfarin
SAaged care2007-01-30

Coroner's Finding: KENT Yvonne Lillian

82y · Female·multi organ failure from burns on a background of aortic stenosis and ischaemic …

…. The bottle ruptured within 30 seconds to a minute, causing burns to 9% of her body. She developed renal failure and multi-organ failure and died 12 days later. The coroner found the death preventable: the carer had re…

geriatric medicineemergency medicinesystemcommunication
VIC2025-04-07

Finding into death of Child A

0y · Male·Unascertained in the setting of a remote head injury

Child A, a six-month-old Aboriginal boy, died from unascertained cause in the setting of a remote head injury sustained during family violence. The father violently assaulted the mother while holding the child unsupporte…

forensic medicinepaediatricscommunicationsystemmethamphetamine
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