20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…
…20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged. Clinical staff per…
49y · Female·Hypoxic brain injury related to tracheostomy complications in form of airway occ…
…h 2018 with delayed diagnosis. Following complex neurosurgery causing Wallenberg syndrome, she required tracheostomy for bulbar dysfunction. On 13 June 2018, she suffered cardiorespiratory arrest due to airway occlusion …
20y · Male·anoxic brain injury following cardio-respiratory arrest caused by hypoxia result…
…0-year-old male died from anoxic brain injury following cardiac arrest caused by hypoxia resulting from tracheostomy tube occlusion. After motor vehicle trauma, he underwent surgery and was eventually transferred to a ge…
49y · Female·Hypoxia due to complications following incision and drainage of a right buttock …
…ing hypoxia; medication errors (Metaraminol infusion continued, Propofol not commenced); and subsequent tracheostomy dislodgement causing further hypoxic events. The chain of preventable errors resulted in permanent brai…
60y · Male·bronchopneumonia as a result of or secondary to cerebral haemorrhage; contributi…
…h pneumonia on 12 October 2004 and despite aggressive ICU management including intubation, ventilation, tracheostomy, and vasopressor support, his condition progressively deteriorated. The coroner found that correctional…
60y · Male·respiratory failure and sepsis complicating acute subdural haematoma
Richard Kartinyeri died 44 days after exiting a moving vehicle during a police pursuit. He sustained a severe right-sided acute subdural haematoma, cerebral contusions and skull fractures requiring emergency neurosurgery…
64y · Female·Haemorrhage into atheromatous plaque, due to coronary atherosclerosis
…nto atheromatous plaque. She suffered an acute cardiac event on 5 May 2008 requiring emergency pacemaker insertion. After three weeks in ICU with mechanical ventilation, she was transferred to a medical ward where an eq…
56y · Female·Complications of motor neuron disease
…ube for feeding and required nocturnal ventilation. An advanced care directive refused CPR, intubation, tracheostomy, and interventions causing excessive discomfort. She was found unresponsive on 12 November 2018, approx…
54y · Male·respiratory failure and acute renal failure due to rhabdomyolysis following trau…
…death became almost inevitable despite comprehensive ICU management including dialysis, intubation, and tracheostomy. Communication breakdown occurred between ICU staff and family regarding withdrawal of treatment.
54y · Male·Respiratory failure secondary to prolonged ventilation for the management of sep…
Christopher McIntosh, a 54-year-old man with type 2 diabetes, died from respiratory failure secondary to sepsis originating from an infected foot ulcer while incarcerated at Hopkins Correctional Centre. The coroner found…
56y · Male·bronchopneumonia complicated by multiorgan failure and hypoxic ischaemic encepha…
Michael Dyball, a 56-year-old prisoner with chronic kidney disease, hepatitis C, and treated oropharyngeal squamous cell carcinoma, collapsed in his prison cell and suffered cardiopulmonary arrest on 28 April 2016. He di…
70y · Male·complications arising from craniofacial resection and orbital exenteration for r…
A 70-year-old man died following complex craniofacial resection and orbital exenteration for right sinonasal adenocarcinoma. Multiple surgical complications occurred including carotid artery injury, cerebral infarction, …
59y · Female·complications of intra-abdominal sepsis, including multi-organ failure and bowel…
…patectomy for cholangiocarcinoma. Key clinical issues included: surgical delays of 20 days between stent insertion and operation (affecting bile duct inflammation and infection risk); post-operative complications of art…
38y · Female·peritonitis with septic shock secondary to perforation of the gastrointestinal t…
… caused by perforation at the gastrostomy stoma site. The perforation likely occurred during difficult reinsertion of a dislodged PEG tube on 21 March 2001. Clinical lessons include: (1) A casual medical officer's asses…
54y · Male·Respiratory failure secondary to prolonged ventilation for management of sepsis …
Christopher McIntosh, a 54-year-old man with Type II diabetes and chronic foot ulcers, died from respiratory failure secondary to sepsis arising from an infected foot ulcer requiring above-knee amputation. He was incarce…
33y · Male·Aspiration due to alcoholic intoxication; coronary atherosclerosis contributed
Adam Anthony Fernandez, aged 33, died from aspiration of food contents while acutely intoxicated (blood alcohol 0.276%) following police attendance at his home on 4 December 2001. After police used capsicum spray to safe…
56y · Male·Acute bronchopneumonia secondary to locally advanced, poorly differentiated squa…
A 56-year-old Aboriginal man died in custody from bronchopneumonia secondary to metastatic hypopharyngeal squamous cell carcinoma. He first presented with sore throat in February 2014 and was referred to ENT clinic in Ap…
62y · Male·Multi-organ infarctions (brain, kidneys, heart) resulting from thromboemboli sec…
Mr TAM, a 62-year-old man with multiple cardiac conditions, died from multi-organ infarction secondary to an atrio-oesophageal fistula that developed after radio-frequency ablation for atrial fibrillation. The fistula is…
53y · Male·Traumatic brain injury sustained from police use of force on 25 February 2016, t…
Neil Banjo, a 53-year-old Aboriginal man, died from traumatic brain injury sustained during a police confrontation on 25 February 2016 in Normanton, Queensland. Officers attended a family birthday party to arrest his int…
80y · Male·aspiration pneumonia
…ore senior surgical review before referral to gastroenterology may have enabled earlier nasogastric tube insertion and reduced aspiration risk; (3) The possibility of paralytic ileus was not considered until the followi…
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