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NSWhospital2026-03-19

Inquest into the death of Eve Brown

42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…

Eve Brown, a 42-year-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ri…

emergency medicinegeneral practicediagnosticcommunicationceftriaxone
WAhospital2025-04-17

Inquest into the Death of Colin Stanley Francis NICHOLSON

69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…

Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…

haematologygeneral practicediagnosticcommunicationparacetamol
NSWhospital2019-10-25

Inquest into the death of Peter SMITH

67y · Male·Gas gangrene with antecedent cause of Clostridium septicum septicaemia

Peter Smith, 67, presented to Cooma Hospital with severe leg muscle cramps and pain on 6 February 2018. Despite appropriate pain management and initial investigation suggesting rhabdomyolysis, he rapidly deteriorated and…

emergency medicinegeneral practicesystemmorphine
TAShospital2018-09-21

Coroner's Finding: Patrick, Robert David

65y · Male·ruptured abdominal aortic aneurysm

A 65-year-old man with recently diagnosed small cell lung cancer presented to a rural hospital with acute back pain. He had a known abdominal aortic aneurysm (73mm) identified on staging scans. The attending nurse docume…

emergency medicinegeneral practicediagnosticcommunicationmorphine
WAhospital2017-01-20

Inquest into the Death of Tamika Patricia Carol ULLRICH

23y · Female·chronic hydrocephalus with brain swelling

A 23-year-old registered nurse with undiagnosed chronic hydrocephalus presented to the ED with neck pain, headache and vomiting. Dr B. assessed her briefly without formal examination or detailed history, prescribed ketor…

emergency medicinegeneral practicediagnosticcommunicationcelecoxib
TAShospital2017-01-03

Coroner's Finding: Summerfeldt; Ian Patrick

48y · Male·sepsis and renal failure due to perforated gastric ulcer

A 48-year-old man with hepatitis C and schizo-affective disorder presented to West Coast District Hospital on 20 October 2014 with severe abdominal pain radiating to the right shoulder tip, generalised tenderness, and a …

emergency medicinegeneral practicediagnosticdelayketorolac
QLDhospital2016-09-15

Mr B, a 41 year old indigenous man - Non-inquest findings

41y · Male·Subdural haematoma

A 41-year-old Aboriginal man with excessive alcohol use presented four times to a rural hospital over one month with headaches. His symptoms were attributed to cluster migraine, then alcohol withdrawal syndrome, despite …

emergency medicineneurologydiagnosticcommunicationdiazepam
VIChospital2012-02-29

Finding into death of Joanne Feeney

40y · Female·Multiple injuries sustained in a fall from a height followed by being struck by …

A 40-year-old woman with a history of substance abuse and a prior suicide attempt in August 2010 presented to Northern Hospital at 2am with chest pain. Diagnosed clinically with pleurisy from lower respiratory tract infe…

emergency medicinepsychiatrysystemmethamphetamine
ACThospital2010-04-30

Inquest Into The Death Of Meg Malaika

39y · Female·heart failure connected to a massive pulmonary embolus as a result of deep vein …

A 39-year-old woman died from acute heart failure due to massive pulmonary embolus from deep vein thrombosis two days after laparoscopic appendicectomy. She presented to ED with abdominal pain and nausea, was diagnosed w…

emergency medicinegeneral surgerymedicationcommunicationheparin

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