Coronial

20 results for nasogastric tube placement

TAShospital2018-11-08

Coroner's Finding: Fenton, Timothy John

57y · Male·sepsis and multiple organ failure secondary to aspiration pneumonia

…d a small bowel ileus after presenting with vomiting and diarrhoea. Following emergency laparotomy, his nasogastric tube was dislodged on 29 August and not reinserted during the morning ward round despite clinical stabi…

emergency medicinegeneral surgeryproceduralcommunicationsodium valproate
VIChospital2023-08-09

Finding into death of Shannon Troy Calvert

51y · Male·Aspiration pneumonia in a man with severe scoliosis and cerebral palsy

…on pneumonia after an aspiration episode. Despite speech pathology assessment, nil-by-mouth status, and nasogastric tube placement, he continued aspirating and deteriorated. The case highlights the challenge of managing…

speech pathologyinfectious diseases
VIChospital2013-08-13

Finding into death of Thelma Katherine Holt

79y · Female·pneumonia in the setting of acute peritonitis due to perforated stomach (operate…

…orbidities including obesity, vascular disease, hypertension, and prior Nissen fundoplication, underwent placement of a second intragastric balloon on 11 September 2008 for weight loss prior to hernia repair. On 30 Janu…

gastroenterologygeneral surgerydiagnosticproceduralsertraline
VIChospital2026-03-19

Finding into death of George Scott Boyens

66y · Male·Complications of multiple sclerosis and left tongue squamous cell carcinoma

…ng a brief palliative care admission. He was admitted in May 2025 with malnutrition and pain, underwent nasogastric tube placement and short-course palliative radiotherapy, but declined further treatment after experienc…

oncologypalliative care
VIChospital2025-02-12

Finding into death of Alexander Cameron

40y · Male·Aspiration pneumonia

…e abdominal pain and vomiting, imaging suggested small bowel obstruction, and he became agitated during nasogastric tube insertion. Ketamine was administered for sedation, he vomited and aspirated during tube placement,…

intensive caregeneral surgeryclozapine
NSWhospital2019-10-08

Inquest into the death of George Kimpton

80y · Male·Vasodilatory shock and multi-organ failure secondary to aspiration and cardiores…

…rest in hospital following colorectal cancer surgery. He had developed a post-operative ileus requiring nasogastric tube placement, which was removed on 4 June when he appeared to be recovering. That evening he develope…

colorectal surgerygeriatric medicinecommunicationsystemmorphine
NSWhospital2019-12-13

Inquest into the death of Lorraine BARNES

85y · Female·sepsis, with aspiration pneumonitis being an antecedent cause. Iatrogenic injury…

…rition and electrolyte disturbances after refusing oral intake from hospital day 5 onwards. A fine-bore nasogastric tube was inserted on 30 April 2016 to provide enteral nutrition but was incorrectly positioned in the r…

general medicinerespiratory medicinediagnosticsystemciprofloxacin
QLDhospital2023-06-26

Searle, William Edward

74y · Male·Aspiration of gastric contents due to paralytic ileus following Whipple surgery …

…mal blood work; and after the CTPA showing abdominal/oesophageal distension. Earlier reinsertion of the nasogastric tube, particularly on evening of 1 March, was deemed outcome-changing. The case highlights the importan…

general surgeryintensive carediagnosticcommunicationadrenaline
NSWcommunity2023-11-07

Inquest into the death of AAB

26y · Male·acute cocaine and alcohol toxicity

AAB, a 26-year-old man with a history of substance abuse and mental health issues, died from acute cocaine and alcohol toxicity while in police custody. He presented to a hotel with agitated, paranoid behaviour and was d…

emergency medicinetoxicologycocaine
NThome2016-06-22

Inquest into the death of Richard Kunia

6y · Male·respiratory failure due to pneumonia

Richard Ted Kunia was a 6-year-old Aboriginal child with multiple serious congenital conditions including cerebral palsy, epilepsy, severe developmental delay, aspiration syndrome, and microcephaly. He was in state care …

paediatricsintensive caremorphine
VIChospital2024-11-29

Finding into death of Michael King

59y · Male·Aspiration pneumonia secondary to recurrent anal squamous cell carcinoma with su…

Michael King, 59, died from aspiration pneumonia secondary to recurrent anal squamous cell carcinoma following total pelvic exenteration surgery in December 2021. He was admitted to Dandenong Hospital with vomiting, leth…

oncologyintensive care
VIChospital2023-03-31

Finding into death of Callie Griffiths-I'Anson

2y · Female·perforated oesophagus secondary to complications of treatment of oesophageal inj…

Callie Griffiths-I'Anson, a 2-year-old girl, died from a perforated oesophagus secondary to complications of treatment for caustic soda ingestion. She ingested caustic dishwashing liquid at a hotel on 11 December 2017 an…

paediatric surgeryanaesthesiacommunicationsystemmidazolam
SAhospital2006-01-12

Coroner's Finding: EVANS Shaun Michael

22y · Male·Mixed Diflunisal and Buproprion (Zyban) toxicity

A 22-year-old man presented to Royal Adelaide Hospital's Emergency Department after taking approximately 110 Zyban (bupropion) tablets as a suicide attempt. Unknown to treating staff, he had also ingested a potentially l…

emergency medicinetoxicologydiagnosticcommunicationbupropion
QLDhospital2007-08-26

Fitter, Maureen

60y · Female·Cardiac tamponade due to ruptured heart due to total parenteral nutrition due to…

…ing bowel surgery. The PICC line was inserted under image intensification with appropriate technique and placement at the SVC-right atrium junction. How the perforation occurred remains unclear—possibilities include mig…

colorectal surgerygastroenterologytotal parenteral nutrition
VIChospital2020-05-25

Finding into death of Chris Perdios

42y · Male·Aspiration pneumonia in the setting of impacted large bowel in a man with intell…

Chris Perdios, a 42-year-old man with intellectual disability, autism, and chronic constipation, died from aspiration pneumonia complicated by an impacted large bowel. He was admitted to hospital on 12 October 2018 with …

intensive careemergency medicinecommunicationsystemquetiapine
NSWhospital2017-03-16

Inquest into the death of Bridgett CURRAH

1y · Female·aspiration of gastric contents due to recent gastroenteritis and vomiting leadin…

Bridgett Currah was a 19-month-old girl with complex medical needs including cyanotic congenital heart disease, gastro-oesophageal reflux, and feeding difficulties. She presented to Mildura Base Hospital on 21 May 2013 w…

paediatricsemergency medicinediagnosticcommunicationomeprazole
VIChospital2024-11-22

Finding into death of RD Z

11y · Male·complications of bowel obstruction in the setting of chronic constipation

…ncy care included incomplete triage assessment, absent blood pressure recordings throughout ED stay, and placement in an unmonitored room. He was transferred to RCH where emergency surgery revealed massive fecal impacti…

gastroenterologypaediatric surgerydiagnosticcommunicationmacrogol
QLDhospital2012-12-06

McNaught, Judith

69y · Female·Septic shock due to biliary peritonitis as a consequence of laparoscopic cholecy…

A 69-year-old woman died of septic shock following bile leak complications after laparoscopic cholecystectomy. Critical failures included: (1) inappropriate transfer to low-dependency unit on post-op day 1 despite consul…

surgeryanaesthesiadiagnosticmedicationmorphine
NThospital2012-10-29

Inquest into the death of Ben James Witham

17y · Male·Multi-organ failure with terminal fungal sepsis (Aspergillus) on a background of…

Ben Witham, a 17-year-old with acute lymphoblastic leukaemia, died from multi-organ failure with terminal fungal sepsis. The critical issue identified was a substantial delay in investigating acute severe abdominal pain …

oncologyhaematologydiagnosticdelaymorphine
NSWhospital2024-05-10

Inquest into the death of Finlay Browne

16y · Male·mid-gut volvulus and bowel obstruction, leading to ischaemic bowel and related c…

…d to his death 71 days later. Systemic failures included: no qualified emergency physician leading care, placement in an unsupervised cubicle, failure to recognise unconscious bias affecting his care, inadequate escalat…

emergency medicinesurgerydiagnosticcommunication

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