Coronial

24 results for positive pressure ventilation

SAhospital2008-11-13

Coroner's Finding: WILSON Edward James

29y · Male·air embolus complicating gunshot wounds to chest

…injury (not direct penetration) that had created a defect allowing air entry into pulmonary vessels under positive pressure ventilation. Air embolus occurred in the coronary arteries, causing left ventricular dysfunction…

trauma surgeryintensive care
VIChospital2014-10-01

Finding into death of Gary Jason Cramer

44y · Male·Influenza B infection

… on 16L O2) and was transferred to ICU where he was started on intravenous antibiotics and non-invasive ventilation. A nasopharyngeal aspirate confirmed Influenza B. After discussion with family, a decision was made aga…

intensive carerespiratory medicineaugmentation
NSWhome2015-06-09

Inquest into the death of Gabriele HANNEMANN

54y · Female·complications related to post-polio syndrome and chronic respiratory weakness; n…

…ad severely compromised lung function (13% predicted capacity) and was transitioning from an iron lung to positive pressure ventilation with incomplete physiological assessment. Multiple factors likely contributed: chron…

respiratory medicinegeneral practicedelayparoxetine
WAhospital2019-11-21

Inquest into the Death of Child SH

5y · Male·aspiration pneumonia with terminal palliative care, in a male child with complex…

… medical needs including unsafe swallowing, recurrent respiratory infections, and required non-invasive ventilation support. During his final admission, a Do Not Resuscitate order was appropriately established after dis…

paediatricsrespiratory medicinesystemmorphine
VIChospital2025-09-29

Finding into death of Baby M

<1y · Female·Perinatal asphyxia

…ior registrar, then successful intubation by the consultant at 15 minutes of life but without effective ventilation achievement. Clinical lessons include: escalation to senior staff could have been marginally earlier (c…

obstetricsneonatologyproceduralcommunicationadrenaline
SAhospital2016-08-25

Coroner's Finding: SMITH Colin Peter

51y · Male·respiratory failure and cardiac failure on a background of chronic obstructive l…

…oyal Adelaide Hospital acutely short of breath and confused. Dr R. appropriately initiated non-invasive ventilation and diuretics, diagnosed acute pulmonary oedema and pneumonia, and issued a Mental Health Act order. Wh…

emergency medicinepsychiatryglyceryl trinitrate
VIChospital2017-01-30

Finding into death of Baby Emma Folwell Kuno

<1y · Female·Hypoxic-ischaemic encephalopathy in the setting of chronic placental insufficien…

Emma, born 26 July 2011, developed severe hypoxic-ischaemic encephalopathy associated with chronic placental insufficiency and died at 4 days old. Her mother reported reduced foetal movements after 34 weeks' gestation, b…

obstetricsmidwiferydiagnosticcommunication
ACThome2022-05-19

Inquest into the Death of PAMELA VANCE

83y · Female·pneumonia with generalised atherosclerosis as a significant contributor

Pamela Vance, 83, died from pneumonia with generalised atherosclerosis as a significant contributor. She had multiple comorbidities including COPD, asthma, sleep apnoea and heart disease, complicated by recent falls and …

respiratory medicinegeneral practice
VIChospital2014-10-01

Finding into death of Raymond John O_Brien

71y · Male·acute myocardial infarction due to coronary artery disease

Raymond O'Brien, a 71-year-old forensic patient with a history of ischaemic heart disease, hypertension, and dyslipidaemia, was admitted to hospital with chest pain in August 2013. Initial diagnosis of non-ST elevation a…

cardiologypsychiatryaspirin
SAhospital2003-12-19

Coroner's Finding: HAWKE Anne Elizabeth

33y · Female·Raised intracranial pressure secondary to thrombosis of the superior sagittal, t…

… angiography were delayed until Tuesday 29 August. The patient died on 30 August from raised intracranial pressure secondary to sagittal sinus thrombosis and venous infarction. Early diagnosis and heparin therapy could h…

neurosurgeryradiologydiagnosticcommunicationoral contraceptive pill
VIChospital2023-10-20

Finding into death of Vanessa Li

<1y · Female·subgaleal haematoma complicating an obstructed labour

… not identified until 7.30am, approximately 6 hours after birth. Earlier recognition and aggressive blood pressure support may have prevented deterioration, though outcome was likely poor. Key lessons: always communicate…

obstetricsneonatologycommunicationdiagnosticoxytocin
NSWhospital2018-06-22

Inquest into the death of Jasmine Chiang

<1y · Female·Hypoxia resulting from primary idiopathic pulmonary hypertension of the newborn …

Jasmine Chiang died at 7 hours of age from primary idiopathic pulmonary hypertension of the newborn (PPHN), probably complicated by pulmonary haemorrhage. She presented with classic PPHN signs (harlequin appearance, diff…

neonatologypaediatricsdelaypethidine
NSWhospital2023-10-31

Inquest into the death of Adam Fitzpatrick

20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…

…not occur for approximately 46 minutes. Staff attempted blind bougie instrumentation and bag-valve-mask ventilation through a displaced tube, causing bilateral tension pneumothoraces. Delays in emergency airway manageme…

intensive careanaesthesiadiagnosticproceduralrocuronium
VIChospital2016-04-19

Finding into death of Noah Cheron-Duncan

<1y · Male·Perinatal asphyxia

Noah Cheron-Duncan, a full-term neonate born at Sandringham Hospital on 19 November 2014, died from perinatal asphyxia. Labour was uncomplicated and FHR monitoring appeared reassuring, but no foetal heart rate was detect…

obstetricsmidwiferycommunicationdelaynitrous oxide
VIChospital2021-11-08

Finding into death of Baby MNL

<1y · Male·Hypoxic ischaemic encephalopathy complicating peri partum asphyxia

A term neonate died at 3 days of age from hypoxic ischaemic encephalopathy due to perinatal asphyxia. The mother presented in early labour, was initially discharged, then readmitted when labour progressed. Labour progres…

obstetricsneonatologysystemcommunicationterbutaline
VIChospital2021-11-18

Finding into death of Pippa May Griffiths

<1y · Female·Neonatal death in the setting of meconium aspiration

A term neonate died from meconium aspiration three hours after spontaneous labour onset. The mother had presented to hospital the previous day with decreased foetal movements and was discharged without comprehensive asse…

obstetricsmidwiferycommunicationdiagnosticbenzyl penicillin
NSWhospital2016-03-11

Inquest into the death of Elsie COGHILL

<1y · Female·Hypoxic ischaemic encephalopathy caused by multiple factors including lung abnor…

Elsie Coghill, a newborn, died from hypoxic ischaemic encephalopathy due to multiple factors including an underlying lung abnormality from antenatal distress, an undetected apnoeic episode during transfer, and undiagnose…

obstetricsneonatologycommunicationsystemoxytocin
QLDhospital2020-08-26

Baby C - non-inquest findings

<1y · Male·meconium aspiration syndrome complicated by persistent pulmonary hypertension

Baby C was born at 41 weeks and 2 days covered in thick meconium with respiratory distress. Key clinical failures included: (1) failure to respond to mother's request for induction at term+6 days; (2) failure to investig…

neonatologyobstetricsdiagnosticproceduralmorphine
NSWcommunity2020-03-25

Inquest into the death of Tory GANDERTON

3y · Male·respiratory failure, with spinal muscular atrophy an antecedent cause

Tory Ganderton, a 3-year-old boy with spinal muscular atrophy (SMA) Type 1, died of respiratory failure during inter-hospital transfer. Admitted to Shoalhaven Hospital on 7 September 2014 with pneumonia and severe malnut…

paediatricsneurologycommunicationsystemadrenaline
VIChospital2022-07-28

Finding into death of H C

<1y · Male·Global cerebral ischaemia secondary to perinatal asphyxia

HC was a neonate who died at 6 days old from global cerebral ischaemia secondary to perinatal asphyxia. He was born following an emergency caesarean section for obstructed labour and fetal distress. Key clinical lessons …

obstetricsneonatologydiagnosticcommunication

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