Coronial
TAS2019-05-10

Coroner's Finding: Russell, Allan Geoffrey

72y · Male·drowning

…ty practices in small commercial fishing operations. Key clinical lessons: importance of lifejacket wear in cold water immersion, cold shock physiology, and supervisor responsibility for verifying worker capabilities bef…

occupational and environmental healthforensic medicinecommunicationsystem
TAScommunity2019-02-12

Coroner's Finding: Lewtas, Georgia Amy

14y · Female·global hypoxic brain injury sustained during drowning

…he water, became exhausted, panicked, and lost consciousness after approximately 12-14 minutes face-down in cold water (14-18°C). Cold water shock likely contributed to her inability to swim effectively. Despite heroic r…

QLDcommunity2017-11-02

Chan, Shui Ki

25y · Male·Hypovolaemic shock and hypothermia due to bilateral pelvic fractures caused by a…

A 25-year-old Chinese tourist died from hypovolaemic shock and hypothermia after being struck by a vehicle while cycling on the Warrego Highway at night. The coroner…

trauma surgeryemergency medicine
WA2020-06-02

Inquest into the Suspected Death of Barry Ray JESSEN

24y · Male·drowning by misadventure following accidental fall overboard from fishing vessel…

…inexperienced maritime workers are vulnerable to accidental immersion; immediate physiological responses to cold-water immersion can prove rapidly fatal; and preventative measures such as properly-fitted lifejackets and …

system
QLDhome2020-03-11

Roulant, Daniel Christopher

22y · Male·Meningococcal meningitis and sepsis

…s and sepsis within 24 hours of symptom onset. He presented to his GP on 23 November 2017 with a viral head cold, low-grade fever (37.4°C), and normal ENT/chest examination. Six days later he became acutely unwell at wor…

general practiceinfectious diseases
QLDhospital2018-07-09

AD - Non-inquest findings

75y · Male·Multi-organ failure secondary to cardiogenic shock and anterior myocardial infar…

… despite diagnostic ECG changes; delayed CT aortogram (ordered to exclude dissection); and transfer to the 'cold' zone of ED despite evolving STEMI. PCI was eventually performed >10 hours post-symptom onset, by which tim…

emergency medicinecardiologydiagnosticcommunicationmorphine
NSWcommunity2017-08-21

Inquest into the death of Samuel SEETO

29y · Male·Florid myocarditis

…d to detect his cardiac condition. He presented on 5 December 2015 with a 3-day history of fatigue, feeling cold, and multiple episodes of syncope including collapse in the waiting room. Dr P. diagnosed viral illness wit…

general practicecardiologydiagnosticcommunicationibuprofen
SA2003-07-24

Coroner's Finding: Whyalla Airlines

21y·Double engine failure and ditching. Primary causes: left engine crankshaft fract…

On 31 May 2000, Piper Navajo Chieftain VH-MZK ditched in Spencer Gulf after two engine failures, killing seven passengers and the pilot, with one person missing. The coroner found that the right engine was damaged by end…

aviation medicinesystemprocedural
VIChome2013-11-27

Finding into death of Andrew Gilmore

17y · Male·intra-abdominal haemorrhage complicating partial pancreatectomy for traumatic pa…

…buting symptoms to medication taken on empty stomach. Pain recurred on 22 May morning with reports of being cold and clammy (suggesting shock), but clinical assessment by on-call registrar unfamiliar with the case result…

general surgeryemergency medicinecommunicationdelayoxycodone
QLDhome2012-12-06

Bramble, Julie Anne

50y · Female·septicaemia

…death, she developed progressive symptoms including weakness, incontinence, diarrhoea/vomiting, shaking and cold extremities—consistent with systemic infection. Her housemates recognised her deterioration and Mr Martin r…

emergency medicineparamedicinedelaycommunicationmethamphetamine
SAcommunity2006-02-22

Coroner's Finding: SINCLAIR-SPAAN Christopher James

21y · Male·Closed head injury and retroperitoneal and pelvic haematoma due to fractured pel…

…d the retrieval team provided high-quality resuscitation, the deceased developed irreversible hypovolaemic shock. Key clinical lessons: (1) Local medical officers should be systematically called to rural trauma scenes d…

intensive caretrauma surgerycommunicationsystem
WAhospital2023-02-22

Inquest into the Death of Aishwarya Aswath CHAVITTUPARA

7y · Female·multiorgan failure due to fulminant sepsis (Streptococcus pyogenes)

…tes in Perth Children's Hospital emergency department. She presented with gastrointestinal symptoms, fever, cold extremities and lethargy but was triaged as low-acuity (category 4). Critical missed opportunities occurred…

emergency medicinepaediatricsdiagnosticcommunication
SAhospital2006-05-12

Coroner's Finding: MARTIN Kirsten Lee

24y · Female·multi organ failure due to meningococcal septicaemia

24-year-old woman presented to ED with fever (40.1°C), headache, myalgia and mild photophobia. RMO Dr R., relatively inexperienced (5 weeks in Australia), examined her thoroughly but focused on excluding meningitis throu…

emergency medicineinfectious diseasesdiagnosticcommunication

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