Coronial

49 results for emergency alerting

NSWcommunity2026-02-05

Inquest into the deaths at Westfield Bondi Junction Volume 2

Female, male·Stab wounds inflicted by Joel Cauchi

…hia) and injured ten others. The inquest examined the preparedness and response of security, police, and emergency services to this unprecedented incident. Key findings identified deficiencies in security control room p…

emergency medicinepublic healthcommunicationsystem
TAShome2022-08-04

Coroner's Finding: Joyce. Kaye Maree

58y · Female·thermal burns

…d 2015, but these were not recognised as indicating potential electrical hazards. The fire alarm delay in alerting her may have been worsened by her antipsychotic medication effects. While the exact ignition mechanism wi…

psychiatrygeneral practicesystempaliperidone
VICcommunity2013-10-21

Finding into death of Rosanne Eve McMonnies

17y · Female·Multiple injuries sustained in collision between semi-trailer and train

…picuity for truck drivers), deficient heavy vehicle brake maintenance (unroadworthy trailer brakes), and emergency response issues including inappropriate air transport of a trauma patient. While some deaths were immedi…

emergency medicinetrauma surgerysystemdelay
VIC2013-10-21

Finding into death of Harold Claude Long

83y · Male·Acute blood loss and shock/trauma in a man with cardiomegaly, myocardial fibrosi…

… immediately from trauma, while others died from severe injuries with poor prognosis despite appropriate emergency response. Harold Long developed a tension pneumothorax during fixed-wing air transport to Melbourne with…

emergency medicineparamedicinesystemproceduralmorphine
VIC2013-10-21

Finding into death of Danielle Louise Meredith

8y · Female·Multiple injuries sustained in collision between semi-trailer and train at level…

…reas: (1) the driver and vehicle factors, (2) level crossing infrastructure and warning systems, and (3) emergency medical response. Key clinical findings include: Mr Scholl, an experienced driver familiar with the cros…

emergency medicinetrauma surgerysystemdelay
NSWaged care2019-12-06

Inquest into the disappearance and suspected death of Raymond Speechley

77y · Male·Hypothermia

…ceeded that afternoon. Clinically, the facility failed to read critical inter-hospital transfer documents alerting staff to his high absconding risk, failed to complete admission risk assessments, and failed to escalate …

geriatric medicineemergency medicinecommunicationsystemrisperidone
VICcommunity2016-11-29

Finding into death of Phillip Richard Anderson

32y · Male·Complications of mixed drug use

…ntervention may have prevented death and was disturbed that passengers observed his deterioration without alerting authorities. Key lessons include the importance of bystander awareness and reporting systems in public sp…

psychiatryforensic medicinecommunicationzuclopenthixol
TAScommunity2017-04-28

Coroner's Finding: Jin, Kang

21y · Male·hypothermia due to exposure

…te clear signs of hypothermia (inability to speak coherently, ataxia), they did not shelter at available emergency huts. Clinical lessons include the importance of clear communication regarding environmental risks, espe…

communicationsystem
NSWPodcast2019-05-10

Inquest into the deaths of Stephanie Jane KING, Ella-Jane KABEALO and Jacob Matthew KABEALO

Female·Drowning

On 3 April 2017, Stephanie Jane King and her two children, Ella-Jane (aged 11) and Jacob (aged 7), died when their vehicle lost traction on Dulguigan Road, North Tumbulgum, NSW, after flooding from Ex-Tropical Cyclone De…

systemdelay
VIC2013-10-21

Finding into death of Ercil Jean Webb

79y · Female·multiple injuries sustained in collision between semi-trailer and train

…oo late to stop. The collision exposed multiple systemic failures: inadequate training of train staff in emergency roles, absent or ineffective coordination between emergency agencies, delayed or inappropriate decisions…

emergency medicinetrauma surgerysystemdelay
QLDcommunity2009-02-10

Lee-Chue, Allan Duncan

45y · Male·acute myocardial infarction due to coronary atherosclerosis

Allan Lee-Chue, a 45-year-old man with severe coronary atherosclerosis, suffered a fatal acute myocardial infarction while in police custody during transport to Mareeba police station. He collapsed suddenly in the police…

cardiologyemergency medicine
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
VIChospital2002-11-29

SULLIVAN Peter

42y · Male·Pulmonary thromboembolism

…for improvement in DVT prevention, particularly in patients with traumatic lower-limb injuries requiring emergency surgery. Recommendations addressed nail gun safety design, industry alerting, and better DVT risk strati…

orthopaedic surgeryanaesthesia
WAcommunity2018-03-23

Inquest into the Death of Ali Mohammad SOLTANI

30y · Male·Drowning

A 30-year-old male drowned at Salmon Holes, Western Australia after being swept off rocks into the ocean while rock fishing. He was not wearing a life jacket. Although he initially surfaced and attempted to swim back to …

emergency medicineforensic medicinesystem
VIC2013-10-21

Finding into death of Chantal Rose Meredith

5y · Female·Multiple injuries sustained in a collision between a semi-trailer and a V/Line p…

…arly. The driver failed to see flashing lights or hear the horn, indicating infrastructure limitations in alerting familiar drivers who aren't expecting trains. Poor maintenance of the semi-trailer's brakes and inadequat…

emergency medicinetrauma surgerysystemdelay
VIC2016-05-23

Finding into death of Katrina Mary West

56y · Female·Hypoxic ischaemic brain injury due to upper airway obstruction by food bolus

…ng mealtimes for clients with communication or swallowing difficulties; and systems to enable rapid staff alerting in emergencies. The coroner found no formal choking risk documented despite family accounts of the patien…

intensive careneurologycommunicationsystemlevetiracepam
WAcommunity2018-03-16

Inquest into the Deaths of Chunjun LI and Jiaolong ZHANG

42y · Male·Drowning

Two fishermen drowned after being swept into rough seas while rock fishing at Salmon Holes. Neither wore life jackets despite dangerous wave conditions. One man was retrieved deceased; the other was never found. Autopsy …

emergency medicineanaesthesiasystem
VIC2021-09-15

Finding into death of Cheryl Anne Taylor

59y · Female·mechanical asphyxia

…learning: this case underscores the importance of understanding structural safety in community settings. Emergency responders provided appropriate care. Key prevention points: balconies require proper initial engineerin…

emergency medicinesystemdelay
QLD2019-03-28

McManus, Vaughn Ross - Non-inquest findings

31y · Male·Multiple injuries from fall from height; multiple drug toxicity (methylamphetami…

…while attempting to reach his dog at the falls' edge. His fiancée performed CPR and successfully located emergency services via satellite phone after hiking over one hour through remote terrain. Key issues identified in…

systemmethamphetamine
SAhospital2023-11-09

Coroner's Finding: Jablanovic, Branko

61y · Male·congestive cardiac failure due to cardiomegaly with left ventricular hypertrophy

A 61-year-old man with diabetes, obesity, and high cholesterol presented to his GP with shortness of breath for 4-5 days and tachycardia (HR 120). The GP diagnosed anxiety instead of cardiac failure, failed to ask critic…

general practicecardiologydiagnosticmedicationpropranolol

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