Coronial

16 results for tracheal intubation

ACThospital2019-06-25

Inquest into the death of Jay Alan Paterson

43y · Male·hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic …

…ossession. Mr Paterson was found unconscious on 31 August with toxic levels of oxycodone and clonazepam. Intubation was technically difficult due to anatomical factors and laryngeal calcification; tracheal perforation oc…

general practicepain medicinesystemproceduraloxycodone
QLDhospital2020-08-26

Baby C - non-inquest findings

0y · 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
SAhospital2000-02-25

Coroner's Finding: STONEHOUSE Jarrod William (aka Scott)

23y · Male·aspiration of blood due to stab wound to trachea

…e haemorrhage from trachea, aspirating blood into airway. Died from aspiration. Autopsy showed 2.5cm deep tracheal penetration. Expert review identified that penetrating neck wounds warrant surgical evaluation and imagin…

emergency medicinesurgerydiagnosticcommunicationalcohol
NSWcommunityPodcast2016-03-15

Inquest into the death of Tommy NGO

19y · Male·ischaemic brain injury after cardiac arrest, brought about by blunt force injuri…

…r leak, pneumothoraces, and aspiration pneumonitis. Bystander CPR could not have prevented death—only endotracheal intubation by paramedics addressed the tracheal rupture. Key clinical lessons: even optimal first aid can…

emergency medicineintensive caresupervisionsystem
NSWhospital2021-10-12

Inquest into the death of Bruce HODGES

78y · Male·cardiorespiratory failure due to complications of tracheal stenosis

…ostomy following laryngeal cancer surgery, presented to hospital with progressive shortness of breath and tracheal stenosis. Over 48 hours of admission, his respiratory rate fluctuated between normal and elevated levels …

emergency medicineENT surgerydiagnosticsystemnebulised saline
NThospital2026-01-09

Inquest into the death of C Guyula

49y · Female·Hypoxia due to complications following incision and drainage of a right buttock …

…e reversal of neuromuscular blockade (Train of Four monitor not calibrated pre-operatively); oesophageal intubation not recognised due to misidentification of an impedance monitor as capnography; delayed detection allowi…

anaesthesiasurgeryproceduralmedicationfentanyl
WAhospital2007-06-08

Inquest into the Death of Rasmussen

31y · Female·cerebral anoxia following attempted intubation pre-surgery in a woman with torti…

…orticollis, dysmorphia, short rigid neck), died on 17 June 2003 from cerebral anoxia following attempted intubation at Joondalup Health Campus. She was admitted for elective left inguinal hernia repair. Dr L., the anaest…

anaesthesiageneral surgerydiagnosticproceduralatracurium
WAhospital2003-08

Inquest into the Death of Richard Christopher Jankowski

39y · Male·Hypoxic brain injury due to respiratory obstruction following surgery for dental…

…operatively, progressive airway swelling developed rapidly, causing complete obstruction. The initial re-intubation attempt was oesophageal rather than tracheal, a critical error not immediately recognised due to apparen…

anaesthesiageneral surgeryproceduralcommunicationpropofol
SAhospital2020-07-09

Coroner's Finding: SHAW Laurel Jean

84y · Female·multi-organ failure arising from Staphylococcal septicaemia

Laurel Jean Shaw, aged 84, died from multi-organ failure secondary to Staphylococcal septicaemia. She was detained under a Mental Health Act order for Lewy Body Dementia when she developed MRSA pneumonia and sepsis on 15…

intensive carepsychiatry
QLDhospital2022-07-08

R - Non-inquest findings

0y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…

…diorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pulmonary oedema requiring intubation. During PICU management, multiple opportunities were missed to verify endotracheal tube positioning: con…

anaesthesiaintensive carediagnosticproceduralpropofol
VIChospital2021-12-16

Finding into death of Fangzhou Shi

24y · Male·Complications of head injuries (operated), sustained in a tram impact (pedestria…

A 24-year-old international student died from catastrophic head injuries sustained when struck by a tram. He was not wearing his prescription glasses, was distracted by his mobile phone, and misjudged his proximity to th…

neurosurgeryintensive caremidazolam
QLDhospital2008-11-28

McVey, Oliver Steven

67y · Male·Complicated endotracheal tube insertion due to or as a consequence of recent clo…

… Steven McVey, a premature twin born at 31 weeks gestation weighing 1036g, died from complications of endotracheal tube re-insertion at 67 days of age. Following successful surgical ligation of a patent ductus arteriosus…

neonatologycardiothoracic surgeryproceduralcommunication
SAhospital2009-12-31

Coroner's Finding: LYNN Matthew John

20y · Male·hypoxic encephalopathy

…halopathy after sustaining head injuries in a motor vehicle collision. While hospitalised in ICU, his endotracheal tube (ETT) became displaced around 12:20am on 23 January 2005, likely moving upward initially with the cu…

intensive careanaesthesiadiagnosticcommunicationpropofol
SAhospital2002-02-28

Coroner's Finding: GALEA Lesley Anne

30y · Female·respiratory failure related to bronchopneumonia following cerebral anoxia due to…

A 30-year-old woman with a previous caesarean section attempted a trial of vaginal delivery. She received Syntocinon augmentation at 6:45 AM without prior cervical assessment and epidural analgesia at 7:35 AM. No vaginal…

obstetricsanaesthesiadiagnosticcommunicationoxytocin
QLD2023-10-03

Findings of the inquest into the death of GLT

46y · Male·Methylamphetamine toxicity and coronary atherosclerosis

A 46-year-old man died in police custody following a domestic violence order breach arrest in Rockhampton, Queensland. The death resulted from a combination of methylamphetamine toxicity, significant coronary artery dise…

emergency medicineintensive carediagnosticdelaymethamphetamine
VIChospital2019-03-01

Finding into death of Madeleine Therese Sobb

25y · Female·Airway obstruction complicating laryngeal dilation for the treatment of subglott…

Ms Sobb, a 25-year-old woman with spondylo-epi-metaphyseal dysplasia causing severe airway abnormalities and subglottic stenosis, died from airway obstruction following laryngeal dilation. She was admitted to ICU with as…

intensive careemergency medicinecommunicationsystemadrenaline

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