Coronial

536 results for trauma assessment

VIChospital2026-03-13

Finding into death of Wayne Ronald Watson

61y · Male·Intracranial haemorrhage and myocardial infarct

…pite concerns about the head injury. He was taken directly to the cardiac catheterisation lab without ED assessment or CT brain imaging. A skull fracture and intracranial haemorrhage subsequently developed, likely exacer…

cardiologyemergency medicinediagnosticcommunicationheparin
NThome2021-11-25

Inquest into the death of Sammy

9y · Female·suicide by hanging

…r found the Aboriginal Placement Principle was not followed: family members offered to care for her, but assessments were delayed or stalled for years on bureaucratic grounds. She had experienced significant trauma inclu…

paediatricspsychiatrysystemdelaymethylphenidate
NSWhome2025-08-28

Inquest into the death of KBS

1y · Male·Blunt force abdominal trauma; laceration of spleen with intra-abdominal haemorrh…

A 14-month-old Aboriginal boy died from blunt force abdominal trauma with a splenic laceration on 13 January 2019. He had multiple injuries documented at autopsy including rib…

paediatricsforensic medicinecommunicationsystemcannabis
TAShospital2025-07-08

Coroner's Finding: Ridgway, Gavin

52y · Male·pulmonary thromboembolism due to pancreatic contusion and necrosis from motorcyc…

… coroner found no clinical management issues at the receiving hospital. The death resulted from the direct traumatic injury and its thromboembolic complication, not from healthcare failures.

trauma surgeryintensive care
VICcommunity2023-07-13

Finding into death of Christopher James Wrigglesworth

59y · Male·Multiple injuries sustained from a tree falling on a motor vehicle (driver)

…ximately 100 minutes before extrication. Despite resuscitative efforts, he died at the scene from multiple traumatic injuries. The coroner found this was a tragic accident caused by tree failure in significant winds. Whi…

emergency medicinetrauma surgeryondansetron
VIChospital2010-01-15

Finding into death of Josephine Cesnik

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

Josephine Cesnik, 76, died from complications of subdural haemorrhage following head trauma on 20 January 2008. She initially concealed the injury, attributing it to a fall, and did not seek medical…

emergency medicineneurosurgerydelaywarfarin
VIChome2023-03-16

Finding into death of Mr W

32y · Male·Hanging

Mr W, a 32-year-old man with lifelong anxiety, previous suicide attempts, and childhood trauma, died by hanging on 5 April 2019. He had been receiving care from a psychologist (Dr C.) and GP (Dr S.) si…

psychiatrypsychologycommunicationescitalopram
VIC2015-01-20

Finding into death of Marjorie Edith St Clair

91y · Female·Multiple injuries sustained in a motor vehicle incident (passenger)

…ious injury in crashes, the coroner found insufficient evidence to recommend mandatory age-based medical assessments. This case highlights the vulnerability of elderly passengers to fatal outcomes from trauma and the com…

forensic medicineemergency medicine
VICcommunity2019-05-15

Finding into death of Desmond John Watson

65y · Male·Neck trauma and severe ischaemic heart disease in the setting of immersion

A 65-year-old experienced kneeboarder died from neck trauma and severe ischaemic heart disease following immersion at a surf competition. He fell from his board durin…

forensic medicineemergency medicinesystem
VIChospital2020-06-29

Finding into death of Colleen Elizabeth Fermanian

45y · Female·Blunt force trauma to the head

Colleen Fermanian, 45, died from blunt force trauma to the head sustained on 24-25 March 2017. She had a history of heavy alcohol use and advanced liver disea…

emergency medicineintensive caremidazolam
VIChomePodcast2023-12-11

Finding into death of Shane Michael Tuck

38y · Male·hanging

…s found deceased by hanging on 20 July 2020. Post-mortem neuropathology confirmed severe stage III chronic traumatic encephalopathy (CTE). He experienced numerous head knocks during football and sustained a serious knock…

neurologypsychiatrycocaine
VICcommunity2014-03-03

Finding into death of Shannon McCormack

22y · Male·Cranial fracture, epidural haemorrhage, marked cerebral oedema and diffuse axona…

…m protective instinct alone. The critical clinical lesson is that any loss of consciousness following head trauma, regardless of initial apparent stability, warrants urgent hospital assessment and neuroimaging to exclude…

emergency medicineneurosurgerydelay
NSWhome2017-12-01

Inquest into the death of AF

3y · Female·peritonitis caused by small bowel perforation due to blunt force trauma

…s caused by small bowel perforation. Expert evidence established the perforation resulted from blunt force trauma, not natural disease or accidental mechanisms. The manner of injury (accidental vs. inflicted) could not b…

paediatric surgerypaediatricscommunicationsystemparacetamol
QLDhome2022-06-17

CJ - Non-inquest findings

14y · Male·Hanging

…abuse, primarily from his father. Child Safety Services involvement began in infancy but failed to apply a trauma-informed or domestic and family violence lens. Despite repeated reports of physical and sexual abuse, suic…

paediatricspsychiatrydiagnosticcommunicationcannabis
TAShospital2019-09-17

Coroner's Finding: O'Brien, Mark Andrew

42y · Male·Multiple traumatic injuries of head and chest sustained in a motorcycle crash

Mark Andrew O'Brien, 42, died from multiple traumatic injuries sustained in a motorcycle crash on 13 January 2017 and died 18 January 2017 at Royal Hobart Ho…

trauma surgeryneurosurgery
TAShospital2025-06-30

Coroner's Finding: Cameron, Hugh Hutton

88y · Male·acute traumatic left cerebral convexity subdural haematoma

…oms of the SDH developed later as blood accumulated. In elderly patients with cerebral atrophy, even minor trauma can cause delayed subdural haematomas. The case highlights that absence of initial neurological signs does…

emergency medicineforensic medicine
NTcommunity2006-06-29

Inquest into the death of Clifford Brown

58y · Male·Multiple injuries occasioned in a motor vehicle accident (broken neck, ruptured …

…ccident on 18 December 2004 at Barrow Creek, NT. The central clinical issue was the inadequate emergency assessment and management by Registered Nurse Ann Paulus at the accident scene. Despite suffering a broken neck, ru…

emergency medicineparamedicinediagnosticcommunication
NTcommunity2020-12-15

Inquest into the death of Fionica James, Katurah Mamarika, Layla Leering

Female·self-inflicted hanging (Fionica and Layla); hanging but circumstances open (Ketu…

… communities, all with documented histories of sexual abuse, domestic violence, STIs, injuries, and severe trauma. All were known to government agencies. Fionica was pursued by an adult male who threatened her family wit…

paediatricspsychiatrydiagnosticcommunicationalcohol
VIChome2013-04-12

Finding into death of Cody Jackson

15y · Male·asphyxiation by hanging

…cluding Child Protection, Youth Justice, and the Adolescent Forensic Health Service. Despite psychiatric assessments identifying depression, anger issues, and trauma, psychiatrists recommended involuntary admission which…

psychiatrypsychologysystemdelay
VIChospital2010-08-30

Finding into death of Anthony Rimanich

59y · Male·Complications arising from blunt force trauma to the head consistent with a fall

… underwent emergency neurosurgery but deteriorated and died 15 days later from complications of blunt head trauma including subdural haemorrhage, bronchopneumonia, and hypoxic organ damage. The coroner found adequate saf…

neurosurgerytrauma surgery
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