Coronial

197 results for sedation

NSWhospital2020-01-31

Inquest into the death of OS

5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …

…psy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with oral sedation comprising morphine, midazolam, and paracetamol. The medications were administered concurrently rather th…

plastic and reconstructive surgeryanaesthesiamedicationproceduralmorphine
VICmental health2015-12-07

Finding into death of Jeffrey John Hartwig

43y · Male·Pneumonia

…The coroner found medical management reasonable and appropriate, but commended subsequent improvements in sedation monitoring policies and training.

psychiatryintensive caremonitoringcommunicationmethadone
WAhospital2012-06-27

Inquest into the Death of LEE

37y · Male·Respiratory arrest in association with medication drug effect and alcohol intoxi…

…misconceived handover suggesting he remained dangerously aggressive. The coroner found the sustained deep sedation was inappropriate; optimal sedation for such patients should maintain rousability. When the patient remov…

emergency medicinepsychiatrymedicationcommunicationchlorpromazine
ACThome2026-03-10

Inquest into the death of [Redacted] Williams

Female·sodium nitrite poisoning

…d wishes to end her life and explored available options. Palliative care practitioners offered palliative sedation therapy (PST) at home, but conflicting medical advice about duration (2 weeks vs a few days) and eventual…

palliative carepsychiatrysodium nitrite
VIChospital2023-06-06

Finding into death of Dianne Linford

63y · Female·Complications following sedation for percutaneous endoscopic gastrostomy (PEG) t…

…-year-old woman with profound disability from cerebral palsy and encephalitis, died from complications of sedation for PEG tube insertion. She had a congenital polymicrogyria, a significant neurological risk factor for a…

anaesthesiagastroenterologyprocedural
QLDmental health2008-01-31

Hauff-Green, Edward Thomas

32y · Male·Systemic sarcoidosis with severe steatosis and acute myocardial infarction

…r-old man with schizophrenia died at a mental health unit shortly after receiving emergency intramuscular sedation (haloperidol 10mg and midazolam 10mg) for acute agitation and refusal of oral medication. While the patie…

psychiatryemergency medicinediagnosticcommunicationhaloperidol
WA2025-07-31

Inquest into the Death of David Kalunda FLYNN

2y · Male·cardiorespiratory arrest in a young child with opioid (morphine) toxicity

…ory arrest due to opioid (morphine) toxicity following an elective circumcision procedure performed under sedation in a general practice setting on 7 December 2021. The procedure was performed by Dr H. at Gosnells Medica…

general practiceanaesthesiamedicationproceduralmorphine
WAmental health2019-05-22

Inquest into the Death of Pamela Edith ASHLEY

64y · Female·fatal cardiac arrhythmia in a lady with obstructed sleep apnoea, obesity and suf…

…ensive monitoring in acute settings, not psychiatric wards; (2) critical information about hypoxia during sedation was lost in handover; (3) no formal clinical observations or continuous monitoring was performed post-sed…

psychiatryemergency medicinecommunicationsystemchlorpromazine
QLDhospital2024-07-30

PATELESIO, Etevise

29y · Female·Hypoxic-ischaemic encephalopathy due to cardiac arrest of undetermined cause

…te behavioural disturbance, requiring physical and chemical restraint. She received 5mg droperidol IM for sedation, which was appropriate given her frailty. However, formal vital sign monitoring post-sedation was not und…

emergency medicineintensive caremonitoringsystemdroperidol
VIChospital2011-06-07

Finding into death of Angelo Lombardo

46y · Male·Coronary artery atherosclerosis

…rar assessment. He died from coronary artery atherosclerosis (underlying cardiac disease), not from overdosedation. Key lessons: avoid excessive sedation without titration; establish clear rapid-sedation guidelines; ensu…

emergency medicinepsychiatrymedicationsystemclonazepam
VIChospital2020-07-14

Finding into death of Gerard Guy Vaz

61y · Male·Undetermined

…nd subsequently died on 5 April 2015 from an undetermined cause. Clinical lessons include: Eastern Health sedation guidelines were not followed; vital sign monitoring ceased at 7:45am on 4 April despite guidelines requir…

psychiatryemergency medicinesystemdelayzuclopenthixol acetate
NSWmental health2019-02-12

Inquest into the death of Kevin O’Halloran

55y · Male·positional asphyxia, with sedation as an underlying risk factor

…disturbance related to medication changes and possible substance use. He received substantial intravenous sedation (75mg midazolam and 35mg haloperidol) over 20 hours at Royal North Shore Hospital ED, which was clinicall…

emergency medicinepsychiatrycommunicationproceduralmidazolam
WAmental health2019-12-20

Inquest into the Death of Jason James Sutherland MALLETT

46y · Male·cardiac arrhythmia in a man with coronary arteriosclerosis and myocarditis

…rlipidaemia. During his final admission, he became extremely agitated due to inability to smoke, required sedation and seclusion, then died overnight while sleeping. Two ECGs performed during admission appeared normal an…

psychiatrycardiologysystemcommunicationquetiapine
TASmental health2022-08-12

Coroner's Finding: Woolley, Jillian

58y · Female·aspiration pneumonia following palliative treatment for frontotemporal dementia

…lley, aged 58, died of aspiration pneumonia on 18 September 2014 at Roy Fagan Centre following palliative sedation for terminal frontotemporal dementia. She had been severely distressed with uncontrolled behavioural and …

geriatric medicinepalliative carelevomepromazine
QLDcommunity2015-12-15

Andrew - Non-inquest findings

34y · Male·Multiple injuries due to a motor vehicle collision against a background of methy…

…an hour of death. Expert toxicology opinion confirmed both drugs impair driving ability, with THC causing sedation, loss of perception, and cognitive effects, while methylamphetamine withdrawal causes intense fatigue and…

forensic medicinetoxicologymethamphetamine
QLDcommunity2024-11-18

Inquest into the death of Ashley Charles Washington

31y · Male·Undetermined

Ashley Washington, a 31-year-old Kamilaroi man, died after police restraint and sedation during arrest in Toowoomba. He was apprehended following a report of property theft and stabbed a police …

emergency medicineparamedicinediagnosticcommunicationmethamphetamine
QLDhospital2005-10-06

Fernandez, Adam Anthony

33y · Male·Aspiration due to alcoholic intoxication; coronary atherosclerosis contributed

…d capsicum spray to safely disarm him, he was transported to Royal Brisbane Hospital. Despite appropriate sedation for aggressive behaviour, he vomited copiously, aspirating semi-solid food that obstructed his airway. Em…

emergency medicineanaesthesiasedatives
TAScommunity2017-04-20

Coroner's Finding: Roberts-Burton, Blaze Christian

31y · Male·Multiple blunt traumatic injuries sustained from being run over by a truck

…r driver. The death resulted from the combined depressant effects of multiple substances causing profound sedation and utter indifference to survival risks.

alcohol
VIChospital2025-06-25

Finding into death of Melanie Louise Gregory

39y · Female·aspiration pneumonia in the setting of general anaesthesia and colonoscopy for i…

…palsy, dysphagia, and sleep apnoea died from aspiration pneumonia following a colonoscopy performed under sedation for investigation of rectal bleeding. She had known increased aspiration risk, which was discussed with h…

gastroenterologyanaesthesia
VIChospital2023-10-06

Finding into death of G A

86y · Female·Bradycardic arrest secondary to relative hypoperfusion while undergoing surgery …

… carcinoma from her left hand with split-thickness skin grafting under local anaesthesia with intravenous sedation. She suffered an unexpected cardiac arrest intraoperatively secondary to bradycardia and hypotension. Des…

dermatologyplastic and reconstructive surgerymedicationpropofol
1210

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