Coronial

215 results for emergency triage

NSWhospital2021-11-09

Inquest into the death of Caitlin CRUZ

3y · Female·complications of Influenza B viral infection

…l signs (undetectable pulse, low respiratory rate, cyanosis) was not reliably conveyed. In the ED, she was triaged as Category 4 rather than higher acuity, experienced another seizure-like episode, but an ECG was not per…

emergency medicinepaediatricscommunicationdiagnosticmidazolam
NSWhospitalPodcast2021-05-07

Inquest into the death of Brent Justin CROUGH

24y · Male·Complications of Brown Snake Bite

…while separating the snake from his dog and was transported to Tamworth Base Hospital. Despite appropriate triage and observation, he developed sudden collapse and cardiac arrest approximately 25 minutes after arrival, w…

emergency medicinetoxicologysystemdelaybrown snake antivenom
WAmental health2015-12-31

Inquest into the Death of Anthony Ian EDWARDS

Female·Multiple causes: Ruby Natasha Nicholls-Diver: ligature compression of neck (hang…

…tempts must trigger enhanced planning; (4) Suicide-related calls demand immediate psychiatric review and emergency triage/ED referral, not delayed appointments; (5) Longitudinal risk factors must be accessible to treati…

psychiatryemergency medicinediagnosticcommunicationantidepressants
SA2021-11-04

Coroner's Finding: Papageorgiou, Theo Nickolas

27y · Male·compression of the neck due to hanging

…r discharge, psychiatric care was fragmented with poor communication between services. Theo presented to emergency twice in January 2016 with worsening suicidal ideation and depression but was inadequately assessed and …

psychiatrygeneral practicediagnosticcommunicationolanzapine
NSWhome2024-12-04

Inquest into the death of HB

1y · Female·Multiple injuries (subdural clot, multiple rib fractures, injuries to liver, blo…

A 20-month-old girl died from fatal injuries inflicted by her mother's partner. She presented to hospital twice in two weeks with suspicious injuries: facial injuries on 7 June attributed to a puppy, and more extensive f…

paediatricsemergency medicinesystemcommunication
NSWhospital2018-10-22

Inquest into the death of Sandra Cree

71y · Female·Ruptured abdominal aortic aneurysm, with coronary artery atherosclerosis contrib…

… While transfer to a tertiary hospital may not have changed the outcome, early recognition and appropriate triage to a facility capable of emergency vascular surgery could have offered marginal survival benefit.

emergency medicinevascular surgerydiagnosticcommunicationgentamicin
SAhome2012-02-20

Coroner's Finding: WYATT David James and WYATT Jakob James

24y · Male·Blood loss due to multiple stab wounds to chest and multiple incised wounds of n…

A 24-year-old man with schizoaffective disorder and substance abuse killed his 2-year-old son and himself in March 2009. The deceased had been released on licence following a mental impairment finding and was subject to …

psychiatrycorrectional healthsystemcommunicationmethamphetamine
NT2013-11-20

Inquest into the death of Sara Lorraine Hampel

21y · Female·Multiple organ failure as a result of overwhelming Streptococcus pyogenes (Group…

…tant access via dedicated lines, document all clinical advice, use telehealth for visual assessment, lower triage heart rate criteria to 110 bpm, and escalate atypical presentations of sepsis immediately.

obstetricsemergency medicinediagnosticcommunicationparacetamol
SAhome2017-07-25

Coroner's Finding: MCKENZIE Deborah Francis

22y · Female·compression of the neck consistent with hanging

22-year-old Deborah McKenzie, an Aboriginal woman, died by hanging on 13 March 2013 after a complex sequence of failures in mental health care and police procedures. She had reported her partner Shane Woods to police for…

general practiceemergency medicinediagnosticproceduralparacetamol
QLDhospital2012-02-21

Vaggs, Lyji

28y · Male·hypoxic brain injury sustained during restraint in the foyer of the Acute Mental…

Lyji Vaggs, a 28-year-old Aboriginal man with schizophrenia, died from hypoxic brain injury sustained during restraint at Townsville Hospital's Acute Mental Health Unit on 13 April 2010. He had declined admission at ED o…

psychiatryemergency medicinediagnosticmedicationolanzapine
SA2020-11-26

Coroner's Finding: KEN Kenneth Ngalatji

68y · Male·compression of the neck with contributing acute myocardial infarction due to cor…

A 68-year-old Aboriginal man died by hanging in his cell at Yatala Labour Prison on 16 April 2015 while experiencing acute myocardial infarction. He was transferred to Yatala for urgent psychiatric assessment following t…

psychiatrycardiologydiagnosticcommunicationolanzapine
NSWcommunity2023-08-25

Inquest into the death of SG

15y · Male·Hanging

A 15-year-old Aboriginal boy with complex trauma history, including physical abuse, parental mental illness, and 40+ child protection reports, disclosed a suicide attempt to his school counsellor in December 2019. A mand…

psychiatrypaediatricscommunicationsystem
VICcommunity2013-10-21

Finding into death of Margaret Eunice Wishart

78y · Female·Blunt force trauma to the head caused by a compressor from a refrigeration unit …

…sed on human factors, lack of standardised human factors data collection, and communications gaps in the emergency response (failure to include ambulance and rail representatives in the incident management committee). T…

emergency medicinetrauma surgerysystemprocedural
NSWmental health2026-02-05

Inquest into the deaths at Westfield Bondi Junction Executive Summary

41y · Male·Gunshot wounds to neck and chest (perpetrator Joel Cauchi); stab wounds (six vic…

… recommendations made regarding deprescribing guidelines, shared care protocols, mental health outreach, emergency services interoperability, and weapons licensing frameworks.

psychiatrygeneral practicediagnosticcommunicationclozapine
ACThome2021-04-29

Inquest into the death of Bradyn Stuart Dillon

9y · Male·Traumatic head injury with diffuse cerebral swelling and subdural haemorrhage ca…

Bradyn Dillon, aged 9, was brutally beaten to death by his father Graham Dillon in February 2016. The inquest examined how multiple agencies—police, child protection, education, and health services—failed to protect him …

paediatricsgeneral practicediagnosticcommunicationmethamphetamine

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