Coronial

215 results for emergency triage

SAhospital2003-03-17

Coroner's Finding: DeIONNO Orazio

40y · Male·ischaemic heart disease due to coronary atherosclerosis

A 40-year-old man presented to an Emergency Department with chest pain lasting approximately a week and a half, presenting with symptoms including a…

emergency medicinecardiologydiagnostictriage
VIChospital2024-09-26

Finding into death of FH C

11y · Male·Sepsis

…ure, was discharged with a viral diagnosis. He re-presented on 15 June appearing critically unwell but was triaged by an incompletely trained nurse who failed to obtain vital signs. He waited 3 hours for medical review w…

emergency medicinepaediatricsdiagnosticcommunicationrisperidone
NThospital2009-06-30

Inquest into the death of Kenneth William Hill

37y · Male·complete blockage of the right anterior descending coronary artery with blood cl…

Kenneth Hill, a 37-year-old Aboriginal man, presented to Royal Darwin Hospital Emergency Department with chest pain and dyspnoea during football training. He was triaged as Category 3 by the tr…

emergency medicinecardiologysystem
VIChospital2020-10-13

Finding into death of BABY C

0y · Male·Myocarditis

…month-old infant, died from myocarditis (viral heart inflammation) after presenting to Sunshine Hospital Emergency Department with fever, breathing difficulty, and cyanosis. He waited 1 hour 52 minutes before receiving …

emergency medicinepaediatricsdiagnosticdelayparacetamol
SAhospitalPodcast2025-07-31

Coroner's Finding: Panella, Anna Vincenza and Skeffington, Bernard Anthony and Jessett, Graham Henry

Unknown·Panella: pulmonary thromboembolism due to left calf deep vein thrombosis; Skeffi…

…ood tests before cardiac arrest. The Inquest examined systemic issues: inadequate patient visualisation at triage, lack of structured handovers, absence of deterioration protocols on ramps, insufficient triage nurse reso…

emergency medicinecardiologycommunicationsystem
SAhospital2007-09-18

Coroner's Finding: MARKANTONAKIS Stefanos

63y · Male·uncontrolled haemorrhage from ruptured aortic aneurysm

…route to hospital on the second callout, the attending ambulance officer failed to communicate this to the triage nurse. The patient was triaged as category four (2+ hour wait) based only on chronic back pain. He was not…

emergency medicineparamedicinediagnosticcommunicationparacetamol/codeine
VIChospital2024-12-02

Finding into death of Baby Patel

0y · Unknown·unascertained

…f sepsis including hypothermia, lethargy, poor feeding, and jaundice. Critical failures in recognition and triage occurred: the infant was inappropriately triaged as Category 3 (requiring review within 30 minutes) in the…

neonatologypaediatricsdiagnosticcommunicationcefotaxime
VIChome2025-06-02

Finding into death of Christina Lackmann

32y · Female·Caffeine toxicity

…icity after ingesting caffeine tablets. She called 000 at 7:49 pm reporting dizziness and numbness but was triaged as non-urgent Code 3. Unable to connect with a secondary triage practitioner and with no welfare check pr…

emergency medicinetoxicologytriagesystemcaffeine
QLDhospital2007-04-05

Smith, Arthur Lawrence

75y · Male·Acute cardiac failure due to mitral valve disease (surgically treated)

…th, black motions, and coughing up pink phlegm (pulmonary oedema). Despite his recent cardiac surgery, the triage assessment directed him to RBWH based primarily on gastrointestinal bleeding symptoms, as TPCH lacked gast…

cardiothoracic surgeryemergency medicinecommunicationdiagnosticadrenaline
VIChomeNew2026-06-24

Finding into death of Sheridan Louise Burnell

24y · Female·Mixed drug toxicity

…021. Her mental health care was reasonable and appropriate. The coroner identified concerns with ambulance triage procedures: the 000 call was prioritized as non-urgent (Priority 3) and referred to Secondary Triage, dela…

psychiatrygeneral practicecommunicationsertraline
NSWhome2025-01-17

Inquest into the death of BG

0y · Male·Concussive brain injury

…sessment due to lack of capacity. The coroner found DCJ should have utilised alternate mandated options at triage beyond allocation. Key clinical lesson: healthcare providers and child protection services must communicat…

forensic medicinepaediatricssystemcommunication
NSWhospital2014-12-19

Inquest into the death of JX

32y · Male·multiple injuries sustained in a fall from height

…atient's psychosis and called the Mental Health Acute Team, the intake officer failed to complete required triage documentation or alert the receiving hospital—breaching mandatory policies. At the Emergency Department, a…

psychiatrypsychologycommunicationsystemvenlafaxine
VIChospital2011-08-31

Finding into death of Barry Wilson Howroyd

78y · Male·Complications of bowel surgery; specifically post-operative chest infection and …

… predisposing to infection. Critical clinical lessons: (1) his initial ED presentation on 7 August was not triaged or recorded despite describing concerning symptoms; (2) communication between referring doctor and imagin…

gastroenterologygeneral surgerycommunicationsystem
VIChospital2012-04-19

Finding into death of James Kellock Bloomfield

53y · Male·severe burns

…childhood sexual abuse). Police transported him to Bairnsdale Hospital but failed to contact mental health triage or remain until psychiatric assessment. Hospital staff did not understand his legal status and he left wit…

emergency medicinepsychiatrycommunicationsystem
WAhospital2013-11-28

Inquest into the Death of Scafidas, Allegra Amelie

0y · Female·Pneumococcal meningitis

Allegra, aged 6 months, died of pneumococcal meningitis after a Healthdirect telephone triage call on 28 April 2010 that resulted in inappropriate home-care advice. She presented with fever (38.9°C), …

paediatricsinfectious diseasesdiagnosticsystemparacetamol
VIChospital2014-02-26

Finding into death of Dean Lovett

21y · Male·dilated cardiomyopathy

…ed investigations until Monday. Dean deteriorated and attended ED on 7 September, where he was incorrectly triaged as Category 4 (rather than Category 3), resulting in a 3-hour delay before medical assessment. Despite ra…

emergency medicinegeneral practicediagnosticdelaymethotrexate
VIChospital2016-10-25

Finding into death of Andrew Michael ODonnell

46y · Male·Pulmonary thromboembolism complicating left calf deep venous thrombosis

A 46-year-old man presented to ED with a two-day history of left calf pain, swelling and numbness. He was triaged to Fast Track and evaluated by an emergency physician who suspected DVT but had no ultrasound available o…

emergency medicinehaematologydiagnosticenoxaparin
WAhospital2012-05-18

Inquest into the Death of Allan

16y · Male·Pneumonia complicating influenza A (H1N1) infection with secondary Staphylococcu…

…1) infection with secondary Staphylococcus aureus septicaemia. He presented to Northam Regional Hospital Emergency Department on 16 September 2010 with fever (39.4°C), vomiting, diarrhoea, and sweating—features of septi…

emergency medicinegeneral practicediagnosticcommunicationmethylphenidate
WAhospital2013-11-08

Inquest into the Death of Nielson, Melissa Ann

24y · Female·hypoxic brain injury following unexplained cardiorespiratory arrest

…blistering rash on 3 September 2009. Dr C. appropriately identified a potentially serious dermatological emergency and arranged urgent transfer to Royal Perth Hospital (RPH), which had dermatology expertise and knowledg…

emergency medicinedermatologycommunicationdiagnosticcefalexin
VIChospital2024-08-19

Finding into death of Matilda Ruby Armstrong

1y · Female·viral respiratory tract infection (Parainfluenza and Respiratory Syncytial Virus…

…l review at the second presentation—10 of 13 paediatric patients in the ED that night were not seen within triage timeframes; and (2) lack of clear parental escalation procedures to alert staff to deterioration. The coro…

emergency medicinepaediatricsdelaysystemparacetamol
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