Coronial
SAaged care2009-10-16

Coroner's Finding: CHILDS Hayden William

77y · Male·hypoxic-ischaemic encephalopathy and cerebral infarction due to upper airway obs…

…objects in his mouth. The handkerchief migrated into his airway by late evening. Nursing staff performed suctioning with a hard plastic device, which compressed the handkerchief further into the airway, causing complete …

geriatric medicineemergency medicinecommunicationsystem
QLDhospital2020-08-26

Baby C - non-inquest findings

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

…investigate elevated fetal heart rate of 160 bpm at last antenatal visit; (3) failure to intubate before suctioning meconium—non-intubated laryngoscopic suctioning did not meet international standards; (4) critical delay…

neonatologyobstetricsdiagnosticproceduralmorphine
VIChospital

Finding into death of Ella Felicity Hitchen

32y · Female·Aspiration pneumonia with severe cerebral palsy as underlying condition

… in 2011 due to aspiration risk. Following a previous aspiration pneumonia admission in November 2019, a suctioning machine was provided and staff were trained. She was admitted on 18 October 2020 with shortness of breat…

respiratory medicinegeneral medicine
TAS2021-03-25

Coroner's Finding: Gibson, Roger Alan

65y · Male·aspiration pneumonia

…nication failures, or preventable factors were identified. Staff attempted supportive measures including suctioning near the end of life.

geriatric medicinepsychiatryrisperidone
VIChospital2013-05-09

Finding into death of Argyrios Carras

38y · Male·Aspiration pneumonia in the setting of cerebral palsy

…tions identified pneumonia/aspiration changes on chest X-ray. Despite intravenous antibiotics and airway suctioning, his condition worsened. Active management ceased on 16 March and palliative care was initiated followin…

respiratory medicineinfectious diseasesdiazepam
QLDhospital2010-05-07

Cramb, Fay - aka Valmae Beck

64y · Female·Haemorrhage into atheromatous plaque, due to coronary atherosclerosis

…erred to a medical ward where an equipment malfunction (fractured in-line suction system nozzle) delayed suctioning of airway secretions. The immediate clinical lesson is that clinicians should ensure proper instruction …

cardiologyintensive caresystem
SAhospital2006-08-18

Coroner's Finding: CAMPANELLA Cosmo Joseph

20y · Male·anoxic brain injury following cardio-respiratory arrest caused by hypoxia result…

…d consciousness and tracheostomies require continuous pulse oximetry monitoring rather than intermittent suctioning alone. Poor nursing documentation and unclear nursing care standards on the general ward were concerning…

intensive careneurosurgerysystemcommunicationmannitol
QLDhospital2022-07-08

R - Non-inquest findings

<1y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…

A 10-month-old boy died following elective cleft palate repair surgery complicated by post-operative respiratory distress and subsequent cardiorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pu…

anaesthesiaintensive carediagnosticproceduralpropofol
VIChospital2011-01-20

Kaseybellastarrgower moyle 453809

<1y · Female·Spinal Muscular Atrophy - Type 1

… received 24-hour inpatient palliative care at Royal Children's Hospital, including nasogastric feeding, suctioning, and morphine analgesia. Her parents resided with her but significant tensions developed with medical st…

paediatricspalliative caremorphine
SAhospital2020-07-16

Coroner's Finding: HANAN Desmond George

90y · Male·pneumonia complicating fractured right neck of femur (operated) on a background …

…ospital-acquired pneumonia developed, treated with intravenous antibiotics and supportive care including suctioning. He died from pneumonia on day 6 of hospitalisation. The coroner found care was appropriate, the Mental …

orthopaedic surgerypsychiatryantibiotics
SAhospital2016-09-12

Coroner's Finding: RAU Edward Morgan

77y · Male·aspiration pneumonia due to dysphagia on a background of dementia

…d intravenous fluids. He deteriorated with persistent chest congestion despite supportive care including suctioning, nebulisers and oxygen. He was found unresponsive on 31 October 2014 and died shortly after. The clinica…

geriatric medicinespeech pathology
NSWhospital2020-06-12

Inquest into the death of Thomas John KEDWELL

66y · Male·respiratory infection on a background of metastatic carcinoma

Thomas Kedwell, aged 66, died in custody at Prince of Wales Hospital from respiratory infection secondary to metastatic carcinoma. He had undergone laryngectomy and tracheostomy for throat cancer in 2017, and presented w…

oncologypalliative carebuprenorphine/naloxone
VIChome2026-07-30

Finding into death of PSD

66y · Female·Acute oesophagitis complicated by gastrointestinal haemorrhage

A 66-year-old woman with cerebral palsy, dysphagia, and chronic reflux oesophagitis presented with acute gastrointestinal bleeding while in supported disability accommodation. She was treated conservatively with IV proto…

emergency medicinegastroenterology
VIChospital2024-02-04

Finding into death of Miranda Louise Lynch

46y · Female·Sepsis of unknown origin

Miranda Lynch, a 46-year-old woman with severe cerebral palsy, spastic quadriplegia, epilepsy, and aspiration pneumonia history, died from sepsis of unknown origin. She was admitted to Box Hill Hospital on 20 April 2023 …

emergency medicinegeneral medicineintravenous fluids
VICaged care2010-10-11

Finding into death of Arthur Moumas

39y · Male·aspiration pneumonia

Arthur Moumas was a 39-year-old man with severe intellectual disability who resided in Colanda Residential Services. He had chronic conditions including severe kyphoscoliosis, epilepsy, osteoporosis, and was dependent on…

general medicineintensive care
VIChospital2023-10-16

Finding into death of Adam Richard Greaves

48y · Male·Aspiration pneumonia complicating progressive degenerative neurological disorder…

Adam Greaves, a 48-year-old man with progressive degenerative neurological disorder, frontotemporal dementia, severe dysphagia, and cerebral palsy, died from aspiration pneumonia after admission to hospital with acute br…

emergency medicineneurology
VIChospital2019-09-16

Finding into death of Marco Angelo Virgona

45y · Male·Aspiration pneumonia with acquired brain injury as a contributing factor

Marco Virgona, a 45-year-old man with acquired brain injury and epilepsy, died from aspiration pneumonia at Frankston Hospital on 23 May 2017. He initially presented to Ambulance Victoria in the morning with vomiting and…

emergency medicineintensive carewarfarin
NTcommunity2012-04-20

Inquest into the death of Lado Stephen Lazorous

4y · Male·drowning

A 4-year-old boy of Sudanese descent drowned at Lake Leanyer Recreation Park on 1 May 2011 despite lifeguard presence. While the facility had been extensively improved following earlier drowning deaths and met RLSSA stan…

systemdelay
SAhospital2011-11-15

Coroner's Finding: TILKA Susan Marie

52y · Female·haemorrhage from a tracheal-innominate artery fistula complicating a tracheostom…

A 52-year-old woman died from catastrophic haemorrhage due to a tracheal-innominate artery fistula 10 days after percutaneous tracheostomy following stroke and decompressive craniectomy. Minor bleeding was observed 3 day…

neurologyintensive care
QLDhospital2009-05-13

Tilse, Therese Josephine

91y · Female·Sub-dural haemorrhage due to head injury due to fall

A 91-year-old woman was admitted to hospital after accidental paracetamol overdose and was found to have had a recent right occipital lobe infarction. While receiving appropriate care, she fell from her hospital bed at t…

emergency medicineradiologyparacetamol

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