Coronial

218 results for asphyxia risk

VIChome2025-07-30

Finding into death of William Charles Heddergott

50y · Male·plastic bag asphyxia in the setting of ethanol intoxication and blunt force head…

William Heddergott, 50, died from asphyxiation with head injuries while intoxicated, in circumstances suggesting his mother Erica (who pleaded guilt…

psychiatrypsychologycommunicationsystemalcohol
VIChospital2011-06-16

Finding into death of Owen Appleby

0y · Male·Hypovolemic shock, metabolic acidosis and coagulopathy in association with subga…

Owen Appleby, born at Portland Hospital after labour induction, developed hypovolemic shock and died at Warrnambool Hospital 17 hours after birth. Ventouse extraction was used to assist delivery; he was born with low APG…

obstetricsneonatologydiagnosticdelayprostin gel
QLDhome2015-10-23

Robertson, Elsie May

39y · Female·Blunt force trauma to the head, on a background of alcohol and cannabis toxicity

…entirely preventable. Key clinical lessons: recognition of escalating intimate partner violence as a lethal risk, the normalisation of violence in some communities reducing help-seeking, and gaps in police response syste…

systemdelayalcohol
QLDhome2019-04-17

Tran, Lucas

0y · Male·Sudden Infant Death Syndrome (SIDS) Category II

…; death was attributed to Sudden Infant Death Syndrome (SIDS) Category II, suggesting possible mechanical asphyxia from an unsafe sleep environment. Clinical lessons include: the partially erected cot and loose towel cov…

paediatricsemergency medicinesystemcommunication
NSW1979-09-03

Inquiry into the fire and deaths at Luna Park

Unknown·Carbon monoxide poisoning and burns (or burns only in one case), accidentally su…

Seven children and teenagers died in the Luna Park Ghost Train fire on 9 June 1979 when the timber-framed building became engulfed in dense smoke and flames. The fire likely originated from a carelessly discarded cigaret…

systemdelay
VIChospital2014-08-28

Finding into death of Lily Irwin

0y · Female·Sepsis

…ssons: (1) Patients declining evidence-based interventions (antibiotics, continuous CTG monitoring) in high-risk situations must be explicitly counselled about risks and consequences, not assumed to be informed; (2) Chor…

obstetricsmidwiferydiagnosticcommunication
NTPodcast2025-10-24

Inquest into the death of Ebony Thompson

1y · Female·hypoxic brain injury caused by pressure to the neck from entrapment on a loop-to…

… in a supervision blind spot behind an island shed; failure to identify and manage entrapment/strangulation risks despite Kidsafe public warnings; inadequate supervision allowing a 10-minute gap in accountability; missin…

paediatricsemergency medicinesystemcommunication
QLDhospital2013-01-18

Ryan, Adam Trent

30y · Male·asphyxia due to hanging (suicide)

…ost-incident. While causation to death cannot be proven, systemic failures in communication, documentation, risk assessment, and medication management created dangerous gaps in care.

psychiatrygeneral practicecommunicationdocumentationsertraline
QLDhospital2014-12-09

Baby A - Non-inquest findings

Male·Hypoxic-ischaemic encephalopathy due to meconium aspiration syndrome

…ot performed despite multiple indications (pre-eclampsia, suspicious admission CTG, meconium-stained liquor risk); water birth was allowed despite being contraindicated in severe pre-eclampsia; and the caesarean section …

obstetricsmidwiferydiagnosticprocedurallabetalol
VIChospital2019-11-11

Finding into death of Finn Moser

1y · Male·Head injury in the setting of labour

Finn Moser was a one-day-old neonate who died from head injury sustained during labour and delivery at the Royal Women's Hospital. He was born to a mother with dichorionic diamniotic twins, induced at 36 weeks due to pre…

obstetricsneonatologydiagnosticcommunicationprostaglandin gel
WAhospital2010-01

Inquest into the Death of West

8y · Male·Hypoxic Ischaemic Encephalopathy resulting from asphyxiation due to co-sleeping …

…el West, an 8-day-old Aboriginal newborn, died from hypoxic ischaemic encephalopathy following accidental asphyxiation due to co-sleeping (bed-sharing) with his mother at Kalgoorlie Regional Hospital on 4 May 2006. The i…

neonatologyintensive caresystemcommunicationmetronidazole
TAScommunity2023-05-19

Coroner's Finding: Kirkwood, Jordan Thomas

19y · Male·hypoxic brain injury following asphyxia due to hanging

…velcro straps on 2 April. The coroner found he should never have been admitted to MHHITH given his imminent risk of self-harm. Critical clinical failures included: (1) Dr W.'s decision to return him to MHHITH after a sec…

psychiatryemergency medicinediagnosticcommunicationfluoxetine
QLDhospital2017-04-04

Coolwell, Bradley Karl

39y · Male·respiratory failure and cardiac arrest

…in seclusion and could not be resuscitated. The coroner found the transfer premature, exposing him to grave risk. Key lessons: blood gas abnormalities indicating serious respiratory illness should have prevented transfer…

emergency medicinepsychiatrydiagnosticcommunicationmidazolam
NSWhome2022-11-04

Inquest into the death of EW

75y · Female·Plastic bag asphyxia in the setting of blunt force head injury

EW, aged 75, died from asphyxiation in July 2019 after being struck by her husband MW, who then took his own life. EW had advancing demen…

geriatric medicineoccupational therapysystemcommunication
SAhospital2008-05-23

Coroner's Finding: KROL Riley

0y · Male·hypoxic ischaemic encephalopathy

Riley Krol, a 11-day-old male infant, died from hypoxic ischaemic encephalopathy following emergency caesarean section delivery on 1 March 2005. After artificial rupture of membranes during labour induction, the foetus d…

obstetricsanaesthesiacommunicationsystemcervedil
QLDhospital2012-10-18

Plumb, Joshua Jai

7y · Male·Joshua died due to a combination of physical entrapment of his head which occlud…

…is mobility and inability to call for help, neither medical nor nursing staff had appreciated this level of risk. Lessons include: team nursing requires explicit documented task assignment; high-dependency children need …

paediatricsemergency medicinecommunicationsystembaclofen
QLDhospital2008-12-15

Harris, Robert

60y · Male·asphyxia sequential to hanging due to depression

Robert Harris, a 60-year-old man with depression, made two suicide attempts within 24 hours. After the first attempt on 27 June 2006, he was discharged from Cairns Base Hospital Emergency Department with a plan to attend…

psychiatryemergency medicinecommunicationdiagnosticfluvoxamine
QLDcommunity2006-12-15

Barlow, Charles Edward; Lusk, Patrick Douglas; Baggott, Emily Jane

asphyxia sequential to hanging (all three cases); Charles Barlow: schizophrenia …

…hours later. Patrick Lusk (66) was admitted with severe depression but received inadequate mental state and risk assessment; discharged after 48 hours without proper mental health referral and died by suicide within hour…

psychiatrygeneral practicediagnosticcommunicationflupenthixol

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