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NSWhospital2014-05-09

Inquest into the death of Brendan BURNS

24y · Male·acute hydrocephalus due to undiagnosed colloid cyst of the third ventricle of th…

Brendan Burns, 24, died from acute hydrocephalus caused by an undiagnosed colloid cyst of the third ventricle. He presented with progressive severe occipital headaches, dizziness, blurred vision, nausea and vomiting over…

emergency medicineneurosurgerydiagnosticcommunicationmorphine
VICcommunity2014-03-19

Finding into death of Darren Brett Kingma

29y · Male·Bronchopneumonia complicating neck injuries sustained in a fall, with Coffin-Low…

A 29-year-old man with Coffin-Lowry Syndrome suffered a severe cervical spinal cord injury from a fall at a respite facility. Disability workers found him on the floor but initially interpreted his presentation as non-co…

emergency medicineradiologydiagnosticcommunicationclonazepam
VIChospital2014-03-13

Finding into death of Kerry Anne Golley

35y · Female·Global cerebral ischaemic injury in the setting of post caecal resection for col…

Kerry Anne Golley, a 35-year-old woman with intellectual disability, autism, and epilepsy, presented with recurrent vomiting between December 2011 and February 2012, requiring multiple ED visits and hospital admissions. …

general practiceemergency medicinediagnosticdelay
VIChospital2014-01-30

Finding into death of Kerri Louise Gunn

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

Kerri Gunn, a 41-year-old woman five days post-caesarean delivery, presented to emergency with frontal headache, elevated blood pressure, proteinuria, abnormal liver function and lower limb oedema. She was admitted under…

emergency medicinegeneral medicinediagnosticdelayparacetamol
SAhospital2013-04-08

Coroner's Finding: MAY Terrill Anthony

69y · Male·subarachnoid haemorrhage with contributing cardiomegaly

A 69-year-old man with hypertension presented with sudden onset severe headache, photophobia, nausea and neck stiffness—classic features of subarachnoid haemorrhage. A CT angiogram identified a 6mm aneurysm on the anteri…

emergency medicineneurosurgerydiagnosticcommunicationperindopril
VIChospital2013-01-29

Finding into death of Abdi Hassan

29y · Male·Acute subdural haematoma

A 29-year-old man died from acute subdural haematoma following blunt head trauma. He was arrested for public drunkenness after a fight with a friend and lodged in police cells where he fell and struck his head on a concr…

neurosurgeryemergency medicinediagnostic
WAhospital2013

Inquest into the Death of Davies, Adriana Elise

46y · Female·brain swelling and dural venous thrombosis in association with low grade glioma …

Dr D., a 46-year-old medical practitioner, died from brain swelling and dural venous thrombosis associated with a low-grade glioma. She presented to Albany Hospital on 10 October 2005 with a severe, different headache ch…

general practiceneurosurgerydiagnosticcommunicationprochlorperazine
WA2013

Inquest into the Death of Banh, Bac Lam

54y · Male·Early bronchopneumonia complicating subarachnoid haemorrhage due to a ruptured b…

Bac Lam Banh, a 54-year-old prisoner at Walpole Work Camp, suffered a ruptured berry aneurysm while working on 4 September 2012. He received prompt first aid from prison staff and emergency responders, with transfer to A…

neurosurgeryemergency medicinediagnosticphenytoin
WAhospital2012-10-05

Inquest into the Death of Rasmussen vaughn

15y · Male·Cerebral ischaemia in a young man with a blocked ventricular peritoneal shunt an…

Vaughn Richard Rasmussen, a 15-year-old boy with congenital abnormalities and a ventricular-peritoneal (VP) shunt, died from cerebral ischaemia caused by acute blockage of his VP shunt on 17 November 2009. Between 12-16 …

general practicegeneral medicinediagnosticcommunicationlamotrigine
SAhospital2012-03-26

Coroner's Finding: SWEETMAN Amber Jayne

10y · Female·congenital hydrocephalus

Amber Jayne Sweetman, aged 10, died from complications of congenital hydrocephalus following delayed diagnosis of a blocked ventriculoperitoneal shunt. She presented to the emergency department with seizures and raised i…

emergency medicineneurosurgerydiagnosticcommunicationmidazolam
VIC2012-01-24

Finding into death of Dominique Cupsa

3y · Male·Complications of severe ischaemic/hypoxic brain injury

A 3-year-old boy with severe hypoxic-ischaemic brain injury from non-accidental trauma sustained at 2 months of age died from complications of that injury while in state care. Medical evidence indicated high-impact head …

paediatricsneurosurgerycommunicationdiagnostic
NT2011-11-18

Inquest into the death of Daniel Phillips Johnson

33y · Male·acute hydrocephalus following ventricular blockage by a colloid cyst

Daniel Johnson, a 33-year-old Aboriginal man, died of acute hydrocephalus caused by a colloid cyst in the brain while in custody at Darwin Correctional Centre. He had complained of severe, recurring headaches for months …

general practiceneurosurgerydiagnosticcommunicationparacetamol
VIChospital2011-02-25

Finding into death of Michael Peysack

69y · Male·Head injury post-collapse secondary to ventricular tachycardia due to ischaemic …

Mr Peysack, a 69-year-old with complex cardiac disease on Warfarin, collapsed at work with witnessed loss of consciousness and occipital laceration. Despite meeting criteria for urgent head CT imaging (age >65, head inju…

emergency medicinecardiologydiagnosticcommunicationwarfarin
VICmental health2010-09-08

Finding into death of Brian O'Connor

73y · Male·Acute on chronic subdural haematoma due to recent head trauma in the context of …

Brian O'Connor, a 73-year-old man with vascular dementia, was admitted to a mental health inpatient unit following aggressive behaviour. He was placed on 15-minute observations due to Level 3 falls risk. Over several wee…

psychiatryneurosurgerydiagnosticsystemfluphenazine
NTpolice custody2010-05-19

Inquest into the death of Cedric Trigger

32y · Male·traumatic subdural haemorrhage resulting from blunt head trauma

A 32-year-old Aboriginal man died from subdural haemorrhage caused by blunt head trauma sustained when climbing over a fence while evading police. He was arrested and brought to Alice Springs watch house in an unresponsi…

emergency medicineneurosurgerydiagnosticcommunication
SAhospital2009-05-21

Coroner's Finding: FARKAS Karl Derek

45y · Male·intracerebral haemorrhage caused by rupture of arterial aneurysm

A 45-year-old man with an intracerebral haemorrhage from a ruptured aneurysm presented to an emergency department and general practice on multiple occasions in October 2005 with headache, vomiting, dizziness, and neck st…

emergency medicinegeneral practicediagnosticcommunicationaspirin
QLDhospital2008-09-12

Neville, Elise Susannah

10y · Female·Head injuries due to fall from a bunk bed

Elise Neville, aged 10, fell from a non-compliant bunk bed and sustained a head injury. At her first ED presentation to Caloundra Hospital at 3:25am, Dr D.—a junior house officer 19 hours into a 24-hour shift—failed to p…

emergency medicineneurosurgerydiagnosticcommunicationmannitol
SAhospital2007-08-02

Coroner's Finding: GILLAM Peter Roy

44y · Male·Sepsis and pulmonary thromboemboli complicating a ruptured cerebral artery aneur…

Peter Gillam, age 44, died from sepsis and pulmonary thromboemboli complicating a ruptured cerebral aneurysm with subarachnoid haemorrhage (SAH). On 16 December 2004, his GP Dr H. referred him urgently for CT head to exc…

emergency medicinegeneral practicediagnosticcommunicationsalbutamol
QLDhome2007-03-22

Dee, Fiona Jane

32y · Female·Hypoxic brain injury due to a combination of factors arising from subdural haema…

A 32-year-old fit and healthy woman died from hypoxic brain injury following complications of spinal anaesthesia for caesarean section. She developed a subdural haematoma (rare complication) and persistent post-dural pun…

obstetricsanaesthesiacommunicationdiagnosticcarbamazepine
SAhospital2006-09-25

Coroner's Finding: McCARTHY Elly Sarahnia

13y · Female·cerebral oedema and infarction secondary to extensive subdural empyema

Elly McCarthy, a 13-year-old girl, died from cerebral oedema and infarction secondary to subdural empyema. She developed fever, headache and neurological symptoms on 24 January 2004 and was initially seen at a GP and Noa…

paediatricsemergency medicinediagnosticcommunicationtrimethoprim

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