Coronial
WAhospital2013

Inquest into the Death of Davies, Adriana Elise

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

…ted with a low-grade glioma. She presented to Albany Hospital on 10 October 2005 with a severe, different headache characterized by pulsatile pain, photophobia, vomiting, and visual disturbances. Dr G. diagnosed migraine…

general practiceneurosurgerydiagnosticcommunicationprochlorperazine
WAhospital2004-08-16

Inquest into the Death of Gregory Andrew Furniss

25y · Male·cerebral craniopharyngioma

… asthma and congenital cataracts, presented to Swan District Hospital on 11 August 2002 with a persistent headache. He was seen by Dr H. (registrar) who diagnosed migraine and commenced symptomatic treatment. He was admi…

emergency medicinegeneral practicediagnosticdelayterbutaline
WAprison2025-04-10

Inquest into the Death of Dannielle Stacey LOWE

41y · Female·complications of intracerebral haemorrhage due to ruptured aneurysm

…ssment occurred across four consultations. On 6 December 2022, Ms Lowe presented with sudden-onset severe headache and three hours of vomiting—a presentation consistent with possible subarachnoid haemorrhage that warrant…

emergency medicineneurosurgerydiagnosticcommunicationparacetamol
SAhospital2009-05-21

Coroner's Finding: FARKAS Karl Derek

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

…rysm presented to an emergency department and general practice on multiple occasions in October 2005 with headache, vomiting, dizziness, and neck stiffness—features consistent with a sentinel bleed. Junior clinicians (a …

emergency medicinegeneral practicediagnosticcommunicationaspirin
TAShospital2017-04-19

Coroner's Finding: Sheedy, Barbara

77y · Female·Large acute subdural haemorrhage leading to uncal herniation subsequent to an ac…

… uninjured with normal neurological examination. However, she developed breathing difficulties and severe headache hours later, which were attributed to pre-existing pulmonary disease. A dilated pupil at 4:25am prompted …

emergency medicinegeneral medicinediagnosticdelaytemazepam
VICcommunity2013-07-04

Finding into death of Rhys Andrew Rodger

16y · Male·Bacterial meningitis

…agnosed with gastroenteritis at a general practice. He presented with a 3-day history of vomiting, severe headache, and fever. The GP recorded a borderline temperature (37°C) and concluded gastroenteritis, prescribing an…

general practiceinfectious diseasesdiagnosticcommunicationparacetamol
SAhospital2004-07-20

Coroner's Finding: QUINN Latoya Shelley

12y · Female·raised intracranial pressure due to ventriculo-peritoneal shunt blockage

…ith congenital hydrocephalus and a ventriculo-peritoneal shunt presented to the ED with severe unrelieved headache after head trauma. An inexperienced junior doctor (6 weeks in role, minimal neurosurgical experience) exa…

emergency medicinepaediatricsdiagnosticcommunicationparacetamol
NT2011-11-18

Inquest into the death of Daniel Phillips Johnson

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

… cyst in the brain while in custody at Darwin Correctional Centre. He had complained of severe, recurring headaches for months before his fatal seizure. The coroner found that while the cause of death was natural and not…

general practiceneurosurgerydiagnosticcommunicationparacetamol
NTcommunity2014-09-01

Inquest into the death of Braydon Brown

17y · Male·bacterial meningitis

…ions in Yuendumu over four days. The critical failure occurred on 1 April when fever (38.3°C), persistent headache, and positive urinalysis were assessed only by a nurse without physician input, despite availability of a…

general practiceemergency medicinediagnosticcommunicationdiazepam
QLDhospital2016-09-15

Mr B, a 41 year old indigenous man - Non-inquest findings

41y · Male·Subdural haematoma

…ld Aboriginal man with excessive alcohol use presented four times to a rural hospital over one month with headaches. His symptoms were attributed to cluster migraine, then alcohol withdrawal syndrome, despite concerning …

emergency medicineneurologydiagnosticcommunicationdiazepam
SA2020-12-18

Coroner's Finding: SCHACHE Leon John

47y · Male·acute subarachnoid haemorrhage with contributing ruptured saccular aneurysm of t…

…e due to a ruptured basilar artery aneurysm while in custody at Adelaide Remand Centre. He presented with headache and dizziness on 6 November 2017, received paracetamol and ibuprofen, and was found unresponsive the foll…

emergency medicineforensic medicineparacetamol
SAhospital2007-08-02

Coroner's Finding: GILLAM Peter Roy

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

…H). On 16 December 2004, his GP Dr H. referred him urgently for CT head to exclude SAH after acute severe headache and neck stiffness. At Modbury Hospital ED on 16 December, a staff member inappropriately told the family…

emergency medicinegeneral practicediagnosticcommunicationsalbutamol
TAShospital2025-04-29

Coroner's Finding: de-identified OQ

41y · Female·frontal lobe ischaemic infarcts (strokes) caused by cerebral artery vasospasm co…

… haemorrhage from a ruptured aneurysm. She presented to multiple healthcare providers over five days with headache, neck stiffness, photosensitivity, vertigo, nausea, vomiting, and a syncopal episode. Critical failures o…

emergency medicineneurosurgerydiagnosticcommunicationchlorpromazine
VICcommunity2025-01-23

Finding into death of Bariyow Mohamed Hussein

50y · Male·Unascertained

…luding alcohol consumption, poor diet, and limited medical engagement. In early January 2024, he reported headaches and cardiac symptoms (tachycardia, palpitations) to his workplace contact. He had two prior ED presentat…

emergency medicinegeneral practicediagnostic
SAhospital2002-02-05

Coroner's Finding: TAYLOR Margaret Joyce

56y · Female·subarachnoid haemorrhage complicating berry aneurysm of the right middle cerebra…

Margaret Joyce Taylor, aged 56, died from subarachnoid haemorrhage due to rupture of a berry aneurysm on the right middle cerebral artery. She presented to three medical practitioners over 6 days with progressive occipit…

general practiceemergency medicinediagnosticcommunicationparacetamol/codeine
VIC2013-05-21

Finding into death of Takashi Le Minh

34y · Male·Acute intracranial haemorrhage, malignant hypertension, renal artery stenosis

…renal artery stenosis died from acute intracranial haemorrhage while in prison custody. He presented with headache and hypertension on 13 June, was transferred to hospital, diagnosed with bilateral renal artery stenosis …

cardiologynephrologywarfarin
VIChospital2010-01-15

Finding into death of Josephine Cesnik

76y · Female·complications of subdural haemorrhage (operation)

…led the injury, attributing it to a fall, and did not seek medical attention for 9 days despite worsening headache. When she presented to the Royal Melbourne Hospital Emergency Department on 29 January with severe headac…

emergency medicineneurosurgerydelaywarfarin
VIChospital2015-07-29

Finding into death of Beatrix Dammers

56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy

A 56-year-old woman presented to Knox Private Hospital with severe headache and eye symptoms on 16 June 2007. An ED physician diagnosed ischaemic stroke based on a subtle CT finding…

emergency medicineneurologydiagnosticmedicationenoxaparin
NSWhospital2023-08-11

Inquest into the death of Andrew Stubbs

32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome

…o conduct risk assessment before escalating dialysis modality, and did not recognise early warning signs (headache) as possible dialysis disequilibrium syndrome rather than lithium toxicity. Clinical lessons include: GPs…

general practicepsychiatrydiagnosticmedicationlithium
WAhospital2022-11-03

Inquest into the Death of Jeffery William ROONEY

41y · Male·subarachnoid haemorrhage due to rupture of a berry aneurysm of the right interna…

A 41-year-old male prisoner died from subarachnoid haemorrhage caused by rupture of an undiagnosed berry aneurysm while incarcerated. He had a complex medical history including migraines, head injuries, hypertension, and…

neurosurgeryemergency medicineamitriptyline

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