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VIChospital2025-09-30

Finding into death of Robert Thoai Dao

73y · Male·Complications of cervical fractures and spinal injury (operated), sustained in a…

A 73-year-old man with multiple comorbidities (diabetes, cardiac disease, liver cancer) slipped on wet tiles outside McDonald's and sustained cervical and thoracic spine fractures with spinal cord injury. Attending param…

paramedicineemergency medicinediagnosticprocedural
VIChospital2025-05-20

Finding into death of Michael Philip Young

67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…

Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pa…

emergency medicineintensive carediagnosticproceduralhydromorphone
TAShospital2024-07-03

Coroner's Finding: Wragg, Dennis Edward

95y · Male·Head injuries (subarachnoid haemorrhage, frontal bone fracture and contrecoup) s…

A 95-year-old man admitted to hospital for fluid overload and cellulitis related to heart failure fell in his hospital room on day 11 of admission whilst attempting to walk to the bathroom without his walker or assistanc…

general medicineneurosurgerysystemprocedural
NSWhospital2022-12-21

Inquest into death of Andrea LESTER

49y · Female·Hypoxic brain injury related to tracheostomy complications in form of airway occ…

Andrea Lester, age 49, suffered a subarachnoid haemorrhage from a PICA aneurysm in March 2018 with delayed diagnosis. Following complex neurosurgery causing Wallenberg syndrome, she required tracheostomy for bulbar dysfu…

neurosurgeryintensive carediagnosticcommunicationtramadol
TAShome2022-05-18

Coroner's Finding: Masters, Shane Anthony

40y · Male·Sudden Unexpected Death in Epilepsy (SUDEP) resulting from post-traumatic brain …

Shane Masters died from Sudden Unexpected Death in Epilepsy (SUDEP) 12 years after sustaining a severe traumatic brain injury at work. On 19 May 2008, a hydraulic jack dislodged while repairing a fully loaded truck in a …

neurosurgeryrehabilitation medicinesystemprocedural
TAScommunity2022-03-14

Coroner's Finding: PL

7y · Male·head injuries from ejection onto rocky riverbank during boating accident

A 7-year-old boy died from catastrophic head injuries after being ejected from a ski biscuit during a recreational boating accident on the Prosser River in Tasmania. The vessel operator was towing the child at excessive …

emergency medicineintensive careproceduralcommunication
VIChospital2021-11-30

Finding into death of Eileen Violet Smith

88y · Female·Head injury in a fall due to atrial fibrillation on anti-coagulants

An 88-year-old woman with atrial fibrillation on anticoagulation died from a subdural haemorrhage sustained in a fall at a rehabilitation hospital. She was assisted to the toilet by a single nursing student despite a doc…

rehabilitation medicineneurosurgeryproceduralcommunication
TAShospital2021-05-24

Coroner's Finding: Lumley, Barry Alyn

81y · Male·acute subdural haematoma

An 81-year-old man suffered a witnessed fall at a shopping centre with head strike to the right parietal region. He presented to the ED with a small haematoma and confusion. The ED team concluded he had a cardiac cause f…

emergency medicinecardiologydiagnosticproceduralparacetamol
TASaged care2021-03-05

Coroner's Finding: Street, Audrey

87y · Female·closed traumatic head injury from a fall at standing height; significant contrib…

An 87-year-old woman with dementia, congestive cardiac failure, and diabetes sustained a fatal closed head injury from a fall in her aged care room overnight. The coroner found that the responsible ECA did not perform th…

geriatric medicineneurosurgeryproceduralcommunication
NSWhospital2021-02-08

Inquest into the death of Simone O'Donnell

24y · Female·Cardiac conducting system disease leading to asystole against a background of a …

A 24-year-old woman with complex congenital cardiac disease, cerebral palsy, and hydrocephalus was admitted to a secondary hospital with a respiratory tract infection and bradycardia with left bundle branch block. She de…

cardiologyemergency medicinesystemcommunicationoxycodone
TAShome2020-12-17

Coroner's Finding: Mitsakis, Stavros

79y · Male·Displaced cervical vertebral fracture with secondary carotid artery dissection r…

A 79-year-old man suffered a catastrophic fall from a 3.5-metre ladder while performing home maintenance work on his property. He had recovered from a stroke three months prior, which may have affected his cognitive func…

neurosurgeryneurologyproceduralsystem
TAShospital2019-07-25

Coroner's Finding: Horcicka, Josef Vratislav

89y · Male·fractured cervical spine (C5 inferior articular process fracture) due to unwitne…

An 89-year-old man with Parkinson's disease fell at home on 16 August 2016, sustaining a cervical spine fracture. Initial CT imaging missed the C5 inferior articular process fracture, reporting only a paraspinal haematom…

orthopaedic surgeryemergency medicinediagnosticproceduralmorphine
QLDaged care2019-06-17

Ms SME - Non-inquest findings

86y · Female·subdural haemorrhage due to or as a consequence of a fall

Ms SME, an 86-year-old resident at a Blue Care nursing home, suffered a fatal subdural haemorrhage following a fall from bed during a sponge bath on 18 January 2016. She died on 21 January 2016. Clinical lessons include:…

geriatric medicineemergency medicineproceduralsystemoxycodone
VIChospital2018-12-03

Finding into death of Anna Agnieszka Bowditch

34y · Female·Complications of fall with fractured ankle and subsequent deep venous thrombosis…

Anna Bowditch, aged 34, died from complications of deep venous thrombosis (DVT) with pulmonary embolism and paradoxical stroke following elective fracture repair surgery. She had multiple known DVT risk factors: immobili…

orthopaedic surgeryanaesthesiaproceduraldiagnosticclonazepam
VIChospital2018-06-04

Finding into death of Bridget Louise Jones

18y · Female·Head injury

Bridget Louise Jones, an 18-year-old university student, was struck by a falling brick wall on Swanston Street, Carlton on 28 March 2013 during high winds (80-100 km/hr). She sustained severe head and multiple other inju…

neurosurgeryemergency medicinesystemproceduralmorphine
NThome2018-04-06

Inquest into the death of Asera aka Ezra Young

70y · Male·blunt force head injury (operated)

A 70-year-old Torres Strait Islander man died from blunt force head injury sustained when police forcibly woke and directed him to leave a private residence where he was sleeping. Police lacked legal powers to intervene:…

neurosurgeryemergency medicineproceduralcommunicationalcohol
VICaged care2017-11-15

Finding into death of Garry Serve

82y · Male·Trauma related intracerebral haemorrhage

An 82-year-old man with dementia, cerebellar ataxia, and mobility limitations fell from his wheelchair down three concrete steps (480cm drop) while attending a hearing aid appointment at an off-site clinic. He sustained …

geriatric medicineemergency medicineproceduralcommunicationfluoxetine
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
VIChospital2017-02-17

Finding into death of Christopher Albert Nance

67y · Male·ischaemic heart disease

A 67-year-old man with ischaemic heart disease and paroxysmal atrial fibrillation underwent arthrotomy for septic arthritis of the knee. He developed post-operative delirium attributed to anaesthesia, analgesics (tramado…

cardiologyorthopaedic surgerycommunicationproceduraltramadol
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

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