Coronial

163 results for retrieval

QLDhospital2016-06-03

James, Kesler Lee

5y · Male·Acute bronchopneumonia and diffuse alveolar damage due to acute rheumatic cardit…

…. Early recognition of the critical acuity could have prompted earlier respiratory support and different retrieval arrangements. The case demonstrates how cognitive biases (diagnostic momentum, framing, confirmation bia…

paediatricsintensive carediagnosticcommunicationfurosemide
NSWhospital2018-10-22

Inquest into the death of Sandra Cree

71y · Female·Ruptured abdominal aortic aneurysm, with coronary artery atherosclerosis contrib…

…ue to password protection issues and inadequate attempts to contact the referring surgeon; (2) the State Retrieval Consultant (Dr N.) became aware of the likely diagnosis but failed to clearly communicate it to either t…

emergency medicinevascular surgerydiagnosticcommunicationgentamicin
NSWcommunity2020-01-24

Into the death of Thomas Redman

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

…dow at a rural property near Gloucester, NSW on 16 December 2015. Despite appropriate pre-hospital care, retrieval, and inter-hospital management, he died approximately 4 hours after injury in a retrieval helicopter en …

emergency medicinetrauma surgerycommunicationsystemoxygen
WA

Inquest into the Death of Jarrod Arthur HAMPTON

22y · Male·drowning secondary to incapacitation from air embolism

…from air embolism. Critical deficiencies were identified: Paspaley lacked emergency procedures for diver retrieval and had failed to conduct rescue drills, resulting in chaotic retrieval once the diver was pulled to sur…

diving medicineoccupational and environmental healthsystemdelay
QLDhospital2018-05-04

LM - Non-inquest findings

1y · Female·Sepsis (Group A Streptococcus)

…hock, delayed intravenous access (three hours), delayed antibiotics and fluid resuscitation, and delayed retrieval initiation. The child deteriorated acutely with petechial haemorrhages and shock, ultimately developing …

general practiceemergency medicinediagnosticdelaymupirocin
NSWhospital2022-12-08

Inquest into the death of Austin Facer

6y · Male·cardiopulmonary arrest on a background of earlier cardiac arrests and resuscitat…

…icular fibrillation and immediate escalation to transfer planning; and (3) the need for clear interstate retrieval protocols between NSW and South Australia. The coroner found the medical treatment Austin received was a…

paediatricsemergency medicinecommunicationsystemadrenaline
SAcommunity2006-02-22

Coroner's Finding: SINCLAIR-SPAAN Christopher James

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

…n rural South Australia. He was trapped for over 2 hours before extrication. Although paramedics and the retrieval team provided high-quality resuscitation, the deceased developed irreversible hypovolaemic shock. Key cl…

intensive caretrauma surgerycommunicationsystem
VIChospital2016-04-14

Finding into death of Kelly Maree Richards

29y · Female·Exsanguination post tubal ligation procedure

…insertion pressure during laparoscopy; the critical importance of accurate handover communication during retrieval to ensure appropriate senior staff involvement and theatre readiness; ensuring regional hospitals have m…

general surgerygynaecologyproceduralcommunicationpacked red blood cells
VIChome2012-07-06

Finding into death of NCS

31y · Male·mixed drug toxicity

…ating significant risk to vulnerable family members. The case highlights need for coordinated medication retrieval protocols involving GPs, police, and ambulance services.

forensic medicinepalliative caresystemfentanyl
QLD2014-12-12

Chen, Ruby Yan

3y · Female·massive air embolism

Ruby Chen, 3 years old, died from massive air embolism during aeromedical transfer from Blackwater to Rockhampton Hospital. The fatal sequence occurred when a paramedic re-spiked a partially-used IV saline bag (containin…

retrieval medicineemergency medicineproceduralsystem
SAhospital2020-07-16

Coroner's Finding: GRAEFE Phillip Brian

62y · Male·Multi-organ failure due to paraquat ingestion

A 62-year-old man with diabetes, renal failure, and hypertension died from multi-organ failure following intentional ingestion of approximately 100-150ml of paraquat. He had recently assumed sole responsibility for the f…

toxicologyemergency medicineparaquat
TAShospital2018-10-17

Coroner's Finding: Jones, Tristan Adam

40y · Male·Subarachnoid haemorrhage due to ruptured right middle cerebral artery aneurysm

…ospital patient swaps; and recognise that rapid diagnosis alone cannot compensate for system failures in retrieval decisions.

emergency medicineneurosurgerysystemcommunicationparacetamol
SAhospital2015-03-06

Coroner's Finding: SIMOS Theodoras Joannas

48y · Male·undetermined

…hospitals managing acutely psychotic patients face significant complexity; early transfer via specialist retrieval (not RFDS/ambulance) may be preferable; careful medication choice considering respiratory sensitivity is…

psychiatrygeneral practicesystemdelayhaloperidol
QLDhospital2008-09-12

Neville, Elise Susannah

10y · Female·Head injuries due to fall from a bunk bed

…ated pupils and GCS 3, there were further delays in intubation and Mannitol administration. The 2.5-hour retrieval to Royal Children's Hospital was unacceptably delayed. Brain death was confirmed and she died on 9 Janua…

emergency medicineneurosurgerydiagnosticcommunicationmannitol
VIChospital2023-05-24

Finding into death of Mr V

73y · Male·Combined effects of cerebrovascular accident and subsequent iatrogenic related i…

…s found to have a left internal carotid artery occlusion with large infarct. Emergency endovascular clot retrieval was performed but the artery was perforated, causing iatrogenic intracranial haemorrhage from which he d…

emergency medicineneurologydiagnosticcommunicationprednisolone
VIChospital2025-08-13

Finding into death of Jordan Thomas Alexander McDonald

0y · Male·complications of extreme prematurity in the setting of precipitant premature bre…

…t was administered 10 times the prescribed morphine dose due to calculation error during a time-critical retrieval scenario. Although this was a serious medication error, the expert evidence concluded the morphine was u…

neonatologyobstetricsmedicationdiagnosticmorphine
NThospital2023-03-15

Inquest into the death of Janelle Pamkal

35y · Female·aortic dissection with associated acute aortitis

…presenting with acute psychosis and chest pain was appropriately referred for psychiatric assessment and retrieval. CareFlight transport was timely and the receiving ED team initiated appropriate chest pain investigatio…

emergency medicinepsychiatryolanzapine
VIChome

Finding into death of Nathan Carl Skewes

31y · Male·mixed drug toxicity

…after patient death. The recommendation was that the Victorian Department of Health establish systematic retrieval mechanisms in consultation with Victoria Police, Ambulance Victoria, and RACGP, particularly for Schedul…

systemfentanyl
NSW2014-04-02

Inquest into the death of Reece POTTER

23y · Male·blunt force head injuries sustained when thrown from his horse during a race

…ker peg system was deemed relatively safe. The case highlights a critical delay in emergency aeromedical retrieval: the available Orange helicopter had insufficient flying hours remaining that day. This unavoidable dela…

systemdelay
TAScommunity2023-12-15

Coroner's Finding: Macpherson James Edward

29y · Male·blunt trauma of the chest

…tion, emergency decompression with a bicycle spoke under remote consultant guidance, CPR, and helicopter retrieval were undertaken. Despite all resuscitation efforts, he died. The coroner found first aid providers acted…

emergency medicineretrieval medicine
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