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NSW2017-11-20

Inquest into the death of Glennon Johnstone

87y · Male·Complications of acute subdural haematoma

An 87-year-old prisoner died from complications of acute subdural haematoma sustained in a fall at Kirkconnell Correctional Centre. He fell while walking in the common area and struck his head on metal fittings. Though p…

neurosurgerygeriatric medicinesystemdelay
QLD2017-11-09

Ackerman, James William

25y · Male·Traumatic subarachnoid haemorrhage due to right intracranial internal carotid ar…

A 25-year-old semi-professional rugby league player died from a traumatic subarachnoid haemorrhage following a carotid artery dissection sustained during a tackle in a June 2015 match. The injury mechanism involved a sho…

emergency medicinesports medicinesystemdelay
QLDhospital2017-10-06

Parsons, Ann

59y · Female·Global cerebral oedema due to hypoxic cerebral ischaemia following cardiac arres…

59-year-old woman admitted with newly diagnosed grade 4 glioblastoma underwent surgery 16 days later after delays during consultant's planned leave. Post-operative complications included ischaemic stroke confirmed on ima…

neurosurgeryintensive carediagnosticcommunicationdexamethasone
NSW2017-06-22

Inquest into the death of David BROWNE

28y · Male·Brain death due to large right acute subdural haematoma sustained as a result of…

David Browne died from brain death due to a subdural haematoma sustained during a professional boxing match on 11 September 2015. The coroner found the death was preventable. Critical failures occurred: the referee did n…

emergency medicineneurosurgerydiagnosticcommunication
QLDhospital2017-05-24

PG - Non-inquest findings

75y · Male·left retroperitoneal haemorrhage associated with lumbar spine surgery

A 75-year-old man with complex comorbidities including Parkinson's disease and cognitive impairment underwent two-stage lumbar spine surgery for degenerative disc disease with stenosis. Post-operatively, he developed a r…

neurosurgeryintensive carediagnosticdelayheparin
NSWhospital2016-12-20

Inquest into the death George TRIANTAFILOPOULOS

75y · Male·acute right subdural haemorrhage sustained in a fall

George Triantafilopoulos, a 75-year-old man on warfarin after aortic valve replacement, suffered two head strikes within 24 hours—first falling onto concrete at a supermarket on 14 August 2014, then falling onto concrete…

general practiceemergency medicinediagnosticdelaywarfarin
NSW2016-11-04

Inquest into the death of Phillip Hughes

25y · Male·traumatic basal subarachnoid haemorrhage due to vertebral artery dissection

Phillip Hughes, a 25-year-old professional cricketer, died from traumatic basal subarachnoid haemorrhage caused by vertebral artery dissection after being struck on the neck by a cricket ball during a Sheffield Shield ma…

emergency medicineneurosurgerycommunicationsystem
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
TAScommunity2016-09-12

Coroner's Finding: Broomhall, Tyler John

23y · Male·intra-cerebral haemorrhage following methylamphetamine use

Tyler John Broomhall, a 23-year-old factory worker, died from intracranial haemorrhage following methylamphetamine use during a football match. He had suffered a prior unreported work-related head injury 4-6 weeks earlie…

emergency medicineintensive carediagnosticdelaymethamphetamine
NThospital2016-09-01

Inquest into the death of Kerry James Murphy

73y · Male·Acute subdural haematoma

Kerry James Murphy, 73, died from acute subdural haematoma following a fall in Royal Darwin Hospital's overcrowded Emergency Department. He was admitted with pneumonia, NSTEMI, and dizziness—significant fall risk factors…

emergency medicinecardiologysystemcommunicationblood thinners
QLDhospital2016-06-16

Mr M - Non-inquest findings

53y · Male·Bilateral ACA stroke

A 53-year-old man presented to the emergency department with acute stroke symptoms (left-sided hemiplegia and dysphasia) with onset around 10:30 am. Due to fluctuating symptoms and delays in stroke team referral, he was …

emergency medicineneurologydiagnosticcommunication
SAaged care2016-02-08

Coroner's Finding: FORD Marie Janet

84y · Female·acute left subdural haematoma

Marie Janet Ford, 84 years old with dementia, fell from a chair at a residential aged care facility and sustained an acute left subdural haematoma. She was on warfarin for deep vein thrombosis and atrial fibrillation. In…

geriatric medicineemergency medicinecommunicationsystemwarfarin
ACThospitalPodcast2015-12-18

AN INQUEST INTO THE DEATH OF CORRINA ANNE MEDWAY

32y · Female·massive postpartum intracerebral haemorrhage of spontaneous hypertensive origin

A 32-year-old woman with Factor V Leiden mutation died from a massive postpartum intracerebral haemorrhage of hypertensive origin five hours after delivering twins. She had been diagnosed with pregnancy-induced hypertens…

obstetricsgeneral medicinediagnosticmedicationlabetalol
TAShospital2015-09-07

Coroner's Finding: Weir, Mary

80y · Female·subdural haematoma due to closed head injury sustained in a fall from bed in hos…

An 80-year-old woman with chronic heart failure admitted to hospital fell from bed and hit her head. Although nursing staff were concerned about a possible head injury, the House Medical Officer incorrectly concluded no …

emergency medicinegeneral medicinediagnosticmedicationaspirin
WAhospital2015-08-12

Inquest into the Death of Helen Christine MacFARLAINE

52y · Female·intracerebral haemorrhage in a lady with underlying cerebrovascular disease and …

A 52-year-old woman underwent right carotid endarterectomy for high-grade stenosis. Post-operatively she developed escalating blood pressure readings (160–220 mmHg), headaches, nausea, agitation, and abnormal behaviour o…

neurosurgeryintensive carecommunicationsystemaspirin
VIChospital2015-07-29

Finding into death of Beatrix Dammers

56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy

A 56-year-old woman presented to Knox Private Hospital with severe headache and eye symptoms on 16 June 2007. An ED physician diagnosed ischaemic stroke based on a subtle CT finding in the absence of focal neurological s…

emergency medicineneurologydiagnosticmedicationenoxaparin
QLDhospital2015-07-27

KS - Non-inquest findings

69y · Male·Intracerebral haemorrhage due to sepsis (Staphylococcus aureus bacteraemia), com…

A 69-year-old man with a history of myocardial infarction and atrial fibrillation presented to a rural hospital with fever, lethargy, tachycardia and elevated troponin. The treating doctor diagnosed NSTEMI based on the e…

emergency medicinecardiologydiagnosticmedicationrivaroxaban
VIChospital2015-04-02

Finding into death of Linda Elizabeth Parker

39y · Female·Hypoxic brain injury secondary to multiple hypovolaemic cardiac arrests from cat…

Linda Parker, aged 39, died from hypoxic brain injury following catastrophic postpartum haemorrhage from placenta increta during caesarean delivery. Critical lessons: (1) Placenta increta risk was not detected prenatally…

obstetricsanaesthesiadiagnosticdelay
VIC2015-03-27

Finding into death of Colin David Johnson

53y · Male·Complications arising from blunt force trauma to the head

Colin David Johnson, aged 53, died from complications of severe blunt force head trauma sustained during an assault in a prison day room on 23 April 2011. The attack occurred in full view of a prison office with a clear …

neurosurgerytrauma surgerysystemdelay
VICaged care2015-03-26

Finding into death of Chang Ying Xu

72y · Female·Hanging

Chang Ying Xu, a 72-year-old Chinese-speaking woman with severe spinal cord compression, chronic pain, and depression, died by hanging during respite care at an aged care facility. While her depression history and multip…

general practicegeriatric medicinediagnosticcommunicationbuprenorphine

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