Coronial
QLDhospital2014-01-31

George, Lynda Margaret - Non-inquest findings

60y · Female·Peritonitis due to anastomotic leak following subtotal colectomy for treatment o…

60-year-old woman died from septic shock due to anastomotic leak following subtotal colectomy for synchronous bowel cancers. Early postoperative bronchospasm complicated clinical assessment, leading focus on respiratory …

general surgerycolorectal surgerydiagnosticcommunication
VIChospital2013-05-10

Finding into death of Joseph Thurgood Gates

<1y · Male·Global cerebral hypoxic injury and perinatal asphyxia secondary to uterine ruptu…

…period. Baby was born in cardiac arrest with Apgar 0 at 1 minute and cord lactate 13.7 (indicating severe hypoxia). Failed intubation during resuscitation contributed minimally. Key failures: lack of early hospital admi…

obstetricsmidwiferydiagnosticcommunication
NSW2011-07-01

Coroner's Finding: Michael Peter Magro

40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…

…by a doctor until 12 hours later, presenting with atrial fibrillation, tachycardia of 185 bpm, and severe hypoxia. He was transferred to hospital, then airlifted to Royal North Shore Hospital with multiple organ failure…

correctional healthgeneral practicediagnosticcommunicationmethadone
SAhospital2014-07-08

Coroner's Finding: SLEEP Aurora Doreen Maureen

<1y · Female·hypoxic-ischaemic encephalopathy attributed to intrapartum asphyxia secondary to…

Aurora Sleep died from hypoxic-ischaemic encephalopathy caused by uterine rupture during labour induction with prostaglandin gel. Her mother had a perforated uterus from a D&C procedure 9 months earlier. The coroner foun…

obstetricsmidwiferycommunicationdiagnosticprostaglandin gel
SAhospital2013-02-08

Coroner's Finding: FENSOM Angela Catherine and TAANKINK Johaanes Andrew

Unknown·Ms Fensom: influenza A (H1N1 2009, pandemic swine flu) with myocarditis causing …

Two deaths from H1N1 influenza in 2009. Ms Fensom (41) died from myocarditis complicating swine flu after inadequate recognition and management of persistent hypotension at Millicent Hospital. Her condition required esca…

emergency medicinegeneral practicediagnosticcommunicationoseltamivir
VIChospital2025-05-13

Finding into death of Baby W

<1y · Male·subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour

Baby W died within 40 minutes of birth from subgaleal haematoma and subarachnoid haemorrhage following a failed instrumental delivery for prolonged labour. The coroner identified critical missed opportunities in decision…

obstetricsneonatologydiagnosticproceduralclindamycin
WAhome2015-06-08

Inquest into the Death of Baby P

<1y · Male·intrapartum hypoxia due to placental abruption

A second twin boy was born at home despite medical advice that twin pregnancies require hospital care. The mother, who strongly preferred home birth, disengaged from hospital when her preferences for birth management (va…

obstetricsmidwiferycommunicationdelay
VIChospital2019-09-26

Finding into death of Tangimama Tavai

35y · Female·Unascertained

A 35-year-old grand multipara with multiple risk factors (BMI >35, smoking, grand multiparity, pregnancy-induced hypertension) presented at 40+4 weeks with absent foetal movements and was induced on Sunday evening. She e…

obstetricsanaesthesiacommunicationsystemoxytocin
SAhospital2014-02-14

Coroner's Finding: RYAN John William and WALTON Patricia Dawn

Unknown·Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…

Two obese patients died from hypoxic-ischaemic encephalopathy following cardio-respiratory deterioration post-operatively at a private hospital without overnight medical cover. John Ryan (54) deteriorated within hours of…

anaesthesiaorthopaedic surgerydiagnosticcommunicationmorphine
SAhospitalPodcast2025-07-31

Coroner's Finding: Panella, Anna Vincenza and Skeffington, Bernard Anthony and Jessett, Graham Henry

Unknown·Panella: pulmonary thromboembolism due to left calf deep vein thrombosis; Skeffi…

Three South Australians died following extended waits on ambulance ramps outside metropolitan hospitals. Anna Panella (76) died from pulmonary thromboembolism; Bernard Skeffington (89) died from aspiration pneumonia afte…

emergency medicinecardiologycommunicationsystem
SAhospital2009-12-31

Coroner's Finding: LYNN Matthew John

20y · Male·hypoxic encephalopathy

Matthew Lynn, aged 20, died from hypoxic encephalopathy after sustaining head injuries in a motor vehicle collision. While hospitalised in ICU, his endotracheal tube (ETT) became displaced around 12:20am on 23 January 20…

intensive careanaesthesiadiagnosticcommunicationpropofol
NSWhospital2019-06-14

Inquest into the death of Melissa King

33y · Female·Hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiop…

Melissa King, aged 33, died from hypoxic ischaemic encephalopathy following in-hospital cardiopulmonary arrest at Blacktown Hospital. She presented with severe malnutrition, electrolyte derangements including hyponatraem…

intensive careendocrinologydiagnosticcommunicationglycoprep
WAhospital2005-09

Inquest into the Death of Maria Donatelli

72y · Female·Peritonitis due to perforated diverticulum in transverse colon

…ximately 22:00 hours on 6 February 2003, with progressively declining blood pressure (85/56 to 70/53) and hypoxia. However, these vital sign changes were attributed to mechanical dehydration and analgesic effects rather…

general surgeryemergency medicinediagnosticcommunicationtramadol
QLDhospital2007-11-06

Huber, Arisa

<1y · Female·sudden unexpected death in infancy due to hypoxic episode while co-bedding with …

Arisa Huber, a newborn, died from sudden unexpected death in infancy (SUDI) due to hypoxic episode while co-bedding with her exhausted mother in a postnatal ward. The infant was found without breathing or pulse at 6:45am…

neonatologyobstetricscommunicationsystem
NTcommunity2009-06-10

Inquest into the death of Robert Plasto-Lehner and David Gurralpa aka Moscow

Male·David Gurralpa: sudden heart attack (coronary atherosclerosis with long-standing…

Two deaths resulted from police restraint in prone positions. David Gurralpa, a 39-year-old Aboriginal man with pre-existing coronary artery disease, died of sudden cardiac arrest following police restraint during a dome…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
SAhospital2014-02-05

Coroner's Finding: COOK Eileen Hazel

76y · Female·hospital acquired pneumonia, multiple organ dysfunction and small bowel obstruct…

Mrs Cook, a 76-year-old woman, died in January 2010 from hospital-acquired pneumonia, multiple organ dysfunction, and small bowel obstruction. She was admitted to a rural hospital with acute renal failure and dangerously…

general practiceemergency medicinediagnosticcommunicationintravenous fluids
WAcommunity2010-04-15

Inquest into the Death of Lynch

20y · Female·food-induced anaphylaxis, likely to peanut allergen

Kylie Lynch, a 20-year-old woman with chronic asthma and a known peanut allergy, died from anaphylaxis on 2 September 2007 in Coral Bay, Western Australia. She consumed desserts at Fin's Café after dining at a nearby hot…

emergency medicinegeneral practicedelaydiagnosticadrenaline
NSWhospital2019-12-17

Inquest into the death of Alan BUGDEN and Amaru BESTRIN

Unknown·Alan Bugden: pulmonary thromboembolism after stroke. Amaru Bestrin: combined dru…

Two deaths occurred in hospital toilets due to undetected collapse in publicly accessible facilities. Alan Bugden, 66, suffered a stroke in an ambulatory care centre toilet at Royal North Shore Hospital and remained unde…

emergency medicineneurologysystemcommunicationheroin
NSWPodcast2021-10-29

Inquest into the death of Jesse DRABSCH

31y · Male·Hypoxic brain injury caused by the exogenous administration of insulin, resultin…

Jesse Drabsch, 31, died from hypoglycaemia after self-injecting insulin in a gym bathroom. A competitive bodybuilder using performance and image enhancing drugs (PIEDs), Jesse entered the bathroom at 5:30pm on 16 Novembe…

endocrinologytoxicologysystemproceduralinsulin
NSWmental health2019-11-22

Inquest into the death of David Dungay

29y · Male·cardiac arrhythmia

…ded David died from cardiac arrhythmia, likely precipitated by the combination of prone restraint-induced hypoxia, poorly controlled diabetes, hyperglycaemia, antipsychotic medications that prolong QT interval, obesity,…

psychiatryemergency medicineproceduralcommunicationmidazolam

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.