Coronial
VIChospital2013-05-17

Finding into death of Francesco Vicendese

81y · Male·Multi-organ failure complicating head, chest and abdominal injuries sustained du…

An 81-year-old man with multiple comorbidities (diabetes, hypertension, chronic renal impairment, past stroke, pacemaker) was struck by a tram while crossing Sydney Road in Brunswick on 29 April 2010. He sustained mu…

trauma surgeryemergency medicine
VIChospital2022-08-29

Finding into death of Helen Welsh

63y · Female·Escherichia coli septicaemia in a lady with multiple comorbidities

Helen Welsh, 63, died from E. coli septicaemia with multiple comorbidities. She presented with respiratory symptoms and underwent bronchoscopy. On discharge day, she deteriorated with fever, altered consciousness, and hy…

cardiothoracic surgeryemergency medicinedelaydiagnosticcarbimazole
NSWcommunity1990-07-18

Newcastle earthquake 1989 findings and recommendations

Multiple traumatic injuries sustained in earthquake-induced building collapse; o…

…urses, and formalising council engineer involvement at disaster sites. One victim died of stress-triggered stroke. Rescue operations were found appropriate, contrary to media criticism.

emergency medicine
VIChospital2026-01-23

Finding into death of Dorothy Anne Simm

74y · Female·Non traumatic intracerebral haemorrhage with further deterioration post medical …

Dorothy Simm, a 74-year-old woman, died from intracerebral haemorrhage with post-operative deterioration following participation in the EVACUATE trial at Monash Medical Centre. She presented with acute right parietal int…

neurosurgeryneurology
VIChospital2022-10-05

Finding into death of Douglas Earnest Stott

72y · Male·Diffuse large B cell lymphoma

Douglas Stott, a 72-year-old prisoner with diffuse large B cell lymphoma, died of natural causes in hospital on 7 January 2021. He had been receiving telehealth oncology consultations while incarcerated but refused in-pe…

oncologyhaematologysystemdelayibrutinib
QLDhome2021-06-15

Bradford, Teresa and Bradford, David - Non-inquest findings

40y · Female·Head injuries inflicted by axe blows in context of intimate partner domestic abu…

Teresa Bradford, aged 40, was killed by her husband David Bradford in a premeditated domestic homicide at their Pimpama home on 31 January 2017, followed by his suicide. She died from head injuries inflicted with an axe.…

general practicepsychiatrycommunicationsystemwarfarin
VIChospital2019-03-19

Finding into death of John Edwin Wilks

76y · Male·Bronchopneumonia complicating fractured ribs sustained in a fall on a bus

John Wilks, a 76-year-old wheelchair user, fell when his wheelchair tilted during a left-turn on a bus on 13 August 2017. He sustained fractured ribs and a small haemothorax. Although initially treated with painkillers, …

intensive carerespiratory medicinesystemdelay
NThospital2005-04-06

Inquest into the death of Peter Wiryal

48y · Male·Cerebrovascular Accident (stroke) caused by subdural haemorrhage, which resulted…

Peter Wiryal, 48, was struck by a white van driven by an intoxicated Daniel Johnson along George Crescent, Fannie Bay at approximately 12:30am on 4 April 2003. He was discharged from Royal Darwin Hospital on 4 April afte…

emergency medicineneurosurgerydiagnosticcommunicationalcohol
QLDhospital2017-09-20

Mr TAM - Non-inquest findings

62y · Male·Multi-organ infarctions (brain, kidneys, heart) resulting from thromboemboli sec…

Mr TAM, a 62-year-old man with multiple cardiac conditions, died from multi-organ infarction secondary to an atrio-oesophageal fistula that developed after radio-frequency ablation for atrial fibrillation. The fistula is…

cardiologycardiothoracic surgerycommunicationsystem
SAcommunity2009-06-30

Coroner's Finding: SALAGARAS Steven

56y · Male·effects of heat exhaustion

Steven Salagaras, a 56-year-old charity collector, died from heat exhaustion on 22 January 2006 after working in extreme heat (40.8°C) during a heatwave. He was observed appearing physically distressed while collecting d…

occupational and environmental healthforensic medicinesystemdelay
WAhome2021-11-29

Inquest into the Death of Ly Minh TONG

38y · Male·Multiple gunshot wounds

A 38-year-old man with a history of methamphetamine use and mental health issues, subject to a violence restraining order, assaulted his father at home. The father reported to police that his son was armed with a knife, …

psychiatrytoxicologycommunicationsystemmethamphetamine
WA2013

Inquest into the Death of Banh, Bac Lam

54y · Male·Early bronchopneumonia complicating subarachnoid haemorrhage due to a ruptured b…

Bac Lam Banh, a 54-year-old prisoner at Walpole Work Camp, suffered a ruptured berry aneurysm while working on 4 September 2012. He received prompt first aid from prison staff and emergency responders, with transfer to A…

neurosurgeryemergency medicinediagnosticphenytoin
SAPodcast2015-01-12

Coroner's Finding: POSNAKIDIS John

42y · Male·multiple injuries sustained when struck by a semi-trailer truck

…pre-employment assessment, severely maladjusted trailer brakes (all six assemblies with excessive push rod stroke lengths), failure to take sufficient rest within fatigue regulations (less than 7 continuous hours in 24-h…

proceduralsystem
VIC2017-09-07

Finding into death of Pamela Louise Elsdon

85y · Female·Multiple injuries sustained as a passenger in a motor vehicle collision

Pamela Louise Elsdon, 85, died from multiple injuries sustained as a passenger in a motor vehicle collision caused by her husband's driving error. Her husband had documented progressive cognitive decline and dementia fro…

emergency medicinetrauma surgerysystemcommunication
VIChome2017

Finding into death of Harold George Nolan

73y · Male·Stab wound to the neck

… neck by his ex-wife Renee Nolan while asleep at home. Ms Nolan was his full-time carer following his 2013 stroke and was experiencing severe carer fatigue, mental health deterioration, financial stress, and paranoid thi…

general practicepsychiatrycommunicationdelayantidepressants
VIChome2023-07-27

Finding into death of Loris Lesley O'Meara

75y · Female·Renal failure and ketoacidosis in a woman with chronic alcoholism and type 2 dia…

A 75-year-old woman with type 2 diabetes and chronic alcoholism died from renal failure and ketoacidosis at home. She was isolated, dependent on her elderly husband for care, and living in squalor. Over 20 disclosures of…

general practicegeriatric medicinecommunicationsystemmetformin
VICcommunity2015-10-09

Finding into death of Paul Robert Washington

36y · Male·Drowning

Paul Washington, 36, drowned while kayaking on Port Phillip Bay on 29 November 2011. His modified recreational kayak lacked proper seaworthiness assessment despite being registered as a powered vessel. Critical failures …

systemdelay
NTcommunityPodcast2018-11-26

Inquest into the death of Wilfried and Gisela Thor

Unknown·Environmental heat injury

Wilfried Thor (75) and Gisela Thor (73), German tourists, died of environmental heat injury after becoming lost at Trephina Gorge, NT. They embarked on a planned short walk on 10 February 2017 when temperatures reached 3…

emergency medicineforensic medicinesystem
VICaged care2024-03-28

Finding into death of Shirley Hill Jones

85y · Female·Complications of a left ankle fracture (operated)

An 85-year-old woman with multiple comorbidities (diabetes, ischaemic heart disease, hypertension, prior stroke) sustained a left ankle fracture requiring surgical repair. A significant delay occurred in removing her p…

geriatric medicineorthopaedic surgerycommunicationdelayoxycodone
VIChospital2015-11-30

Finding into death of Maria Dolores Coliero

69y · Female·Inadvertent intravenous administration of oral ciprofloxacin in the setting of a…

A 69-year-old woman with stroke, diabetes, atrial fibrillation and osteomyelitis died from inadvertent intravenous administration of crush…

intensive careinfectious diseasesmedicationproceduralciprofloxacin

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