Coronial

14 results for venous infarction

NSWhospital2015-03-16

Inquest into the death of John Gibson

63y · Male·Right cerebral infarction caused by infusion of medication via central venous li…

…ry depression, hypernatremia and alcohol withdrawal requiring benzodiazepines and BiPap support. A central venous line was inserted for medication access prior to transfer to ICU. The line was inadvertently placed in the…

surgeryanaesthesiaproceduraldiagnosticdiazepam
VIChospital2015-03-25

Finding into death of Rodney Soffer

58y · Male·ischaemic bowel; chronic megacolon in the setting of constipation, hypothyroidis…

…in days with worsening distension and died shortly after readmission. The autopsy revealed sigmoid colon infarction with scattered early thrombi in mesenteric veins, likely secondary to compression from the markedly dila…

colorectal surgeryemergency medicinemidazolam
VIChomeNew2026-06-19

Finding into death of Elizabeth Jean Hanlon

38y · Female·Pulmonary thromboembolism secondary to deep venous thrombosis due to promethazin…

Elizabeth Jean Hanlon, aged 38, died from pulmonary thromboembolism secondary to deep venous thrombosis following a promethazine overdose. She had complex mental health diagnoses including borderline…

psychiatryintensive carepromethazine
SAhospital2003-12-19

Coroner's Finding: HAWKE Anne Elizabeth

33y · Female·Raised intracranial pressure secondary to thrombosis of the superior sagittal, t…

…r 50 minutes showed significant progression with increased mass effect. However, the diagnosis of cerebral venous thrombosis (CVT) was not pursued despite radiologists recommending MRI. Poor communication between radiolo…

neurosurgeryradiologydiagnosticcommunicationoral contraceptive pill
VIChospital2024-03-15

Finding into death of Kathleen Mary Savage

67y · Female·Pulmonary thromboembolism arising from deep vein thrombosis of the left leg

…sed immediately after discharge. The coroner found that Alexandra District Health failed to assess her for venous thromboembolism risk or prescribe appropriate prophylaxis despite her being largely immobilised in bed for…

general practiceemergency medicinediagnosticdelay
NSWhospital2014-09-11

Inquest into the death of Stanley LORD

39y · Male·dilated cardiomyopathy

…n custody at Prince of Wales Hospital. He had a long-standing cardiac history including prior myocardial infarction, presenting acutely with cholecystitis, acute kidney injury, and multi-organ failure. The coroner found …

cardiologyintensive care
NSWhospital2014-12-05

Inquest into the death of Edna Beryl WHALEN

89y · Female·Pulmonary embolism due to deep venous thrombosis

Edna Beryl Whalen, aged 89, died from pulmonary embolism secondary to deep vein thrombosis following delayed diagnosis of a femoral neck fracture. She fell on 8 January 2007 at an aged care facility and reported hip pain…

emergency medicineorthopaedic surgerydiagnosticdelay
VIChospital2014-01-30

Finding into death of Kerri Louise Gunn

41y · Female·Intracerebral haemorrhage secondary to Posterior Reversible Encephalopathy Syndr…

… McKenzie. A CT brain performed that evening was reported as normal. Despite clinical concern for cerebral venous thrombosis documented on the request form, further investigation with MRI was not pursued as Mrs Gunn impr…

emergency medicinegeneral medicinediagnosticdelayparacetamol
TAShospital2019-10-17

Coroner's Finding: Davies, Eva Fay

87y · Female·left frontal temporal subdural haematoma following closed head injury sustained …

…n deteriorated; she was eventually transferred for emergency surgery but subsequently developed cerebral infarction and died. The coroner recommended all hospitals develop anticoagulation reversal protocols to standardis…

neurosurgeryemergency medicinecommunicationdiagnostic
VIC2025-05-12

Finding into death of Aileen Mary McLeish

54y · Female·Pulmonary thromboembolism complicating left calf deep venous thrombosis in the s…

…with frontotemporal dementia and Parkinson's disease died from pulmonary thromboembolism complicating deep venous thrombosis. She fell during the night at a disability accommodation facility and was found on the floor at…

geriatric medicineemergency medicinecommunicationsystemnordiazepam
TAShospital2018-01-23

Coroner's Finding: Mr M

41y · Male·large volume thrombotic stroke within the distribution of the right posterior ce…

…ad, an MRI was delayed 4 days. When the MRI eventually revealed basilar artery thrombosis with extensive infarction on 10 September afternoon, the LGH radiology department failed to contact NWRH clinicians, and NWRH staf…

emergency medicineneurologydiagnosticcommunication
SAhospital2011-03-28

Coroner's Finding: ALLAN Vera

81y · Female·Severe cardiogenic shock complicating cardiac surgery

An 81-year-old woman died of severe cardiogenic shock following elective aortic valve replacement complicated by intraoperative haemodynamic instability and inadequate postoperative ICU management. The surgery involved e…

cardiothoracic surgeryanaesthesiamedicationcommunicationadrenaline
VIChospital2015-06-12

Finding into death of Baby Chloe Lee Kellett

5y · Female·Cerebral hypoxic and ischaemic injury in a setting of clinical birth asphyxia

Chloe Kellett was born at 39 weeks gestation after induction of labour for rupture of membranes and group B streptococcus positivity. She was delivered by forceps in theatre for a non-reassuring cardiotocogram (CTG) trac…

obstetricspaediatricsdiagnosticcommunicationoxytocin
VIChospitalPodcast2026-02-20

Finding into death of James Harilaos Tsindos

17y · Male·Hypoxic Ischaemic Encephalopathy Complicating Anaphylaxis

James Tsindos, a 17-year-old with known nut allergy and mild asthma, experienced anaphylaxis after inadvertently ingesting cashews in a vegan restaurant meal on 27 May 2021. Ambulance paramedics administered two doses of…

emergency medicineallergy and immunologydiagnosticcommunicationadrenaline (epinephrine) intramuscular

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