Coronial

312 results for severe brain injury

WAhospital2020-09-23

Inquest into the Death of PT (Name Subject to Suppression Order)

5y · Female·aspiration of vomit with microscopic early pneumonia, in a child with a history …

A five-year-old girl with cerebral palsy and epilepsy resulting from non-accidental head injuries at two months old died from aspiration of vomit with early pneumonia. Critical lessons: bruising in non-ambulant infants i…

paediatricsgeneral practicediagnosticcommunicationtopiramate
VIChospital2022-02-22

Finding into death of Matthew Lee Dongelmans

30y · Male·Complications of methylamphetamine toxicity

Matthew Dongelmans, aged 30, died from complications of methylamphetamine toxicity after being arrested for breaching a family violence intervention order. He consumed methylamphetamine prior to arrest, likely in panic w…

emergency medicineintensive caredelaysystemmethamphetamine
VIChome

Finding into death of E H

51y · Male·Complications of chronic ethanol use

EH was a 51-year-old man with chronic alcohol dependence, liver cirrhosis, and recent hip fracture complications who died at home on 1 November 2022 whilst waiting for an ambulance. He had self-discharged from St Vincent…

emergency medicineorthopaedic surgerysystemdelayalcohol
QLDhospital2025-10-24

Non-Inquest findings into the death of Ms G

76y · Female·Head injury comprised of subdural haematoma, subarachnoid haemorrhage with brain…

A 76-year-old woman died from complications of a severe head injury sustained in a motor vehicle collision. She was initially managed conservatively at a regional…

neurosurgeryemergency medicinecommunicationdelay
VICaged care2022-07-06

Finding into death of Catherine Ann Collier

51y · Female·Aspiration in the setting of end stage down syndrome

Catherine Ann Collier, a 51-year-old woman with Down syndrome, end-stage hydrocephalus, and severe dysphagia, died from aspiration pneumonia following a choking episode while eating. The Disability Service…

neurologyspeech pathologysystemcommunicationsodium valproate
QLD2010-07-09

Mataia, Tofia Josen

32y · Male·Cardiac arrest as a result of the combined effects of severe coronary atheroscle…

…assaulting officers. He collapsed during a 2-minute prone restraint by five officers. The autopsy revealed severe coronary atherosclerosis but the coroner concluded death resulted from combined effects of cardiac disease…

psychiatryemergency medicinediagnosticcommunicationsodium valproate
ACTcommunity2014-01-20

Inquest Into The Death Of Brody Lee Oppelaar

0y · Male·Motor vehicle collision injuries

On 20 March 2010, a motor vehicle collision on Canberra Avenue, Narrabundah, ACT, killed four people: an infant (Brody Lee Oppelaar, 3 months), his father (Scott Raymond Oppelaar, 33), his mother (Samantha Leanne Ford, 2…

emergency medicinetrauma surgeryalcohol
WAhospital2015-01-15

Inquest into the Death of Petra ZELE

28y · Female·hypoxic brain injury following cardiac arrest in association with pulmonary hype…

Petra Zele, a 28-year-old woman, died from hypoxic brain injury following cardiac arrest due to acute pulmonary embolism superimposed on chronic thromboembolic pul…

emergency medicinecardiologydiagnosticcommunicationyasmin
WAhome2025-02-12

Inquest into the Death of Kimberley Michael VULICH

64y · Male·complications in association with thermal injuries in a man with underlying chro…

… lit a fire in his caravan for light and heat (having no electricity) which burned out of control, causing severe thermal injuries. Key lessons: establish alert flags in digital records for patients with guardianship ord…

general medicinegeriatric medicinecommunicationdelay
VIChome2021-08-04

Finding into death of NB

1y · Male·Global cerebral ischaemia in an infant with upper airway obstruction

…g overnight nursing support in foster care, suffered a cardiac arrest on 17 December 2016 that resulted in severe hypoxic brain injury and death. The overnight nurse (Ms Jarina) failed to recognise early signs of tracheo…

respiratory medicineintensive carediagnosticcommunication
VIChospital2013-05-10

Finding into death of Joseph Thurgood Gates

0y · Male·Global cerebral hypoxic injury and perinatal asphyxia secondary to uterine ruptu…

Joseph Thurgood-Gates died at 5 days old from global cerebral hypoxic injury due to uterine rupture during labour. The death was preventable. His mother, Ms Thurgood, had two prior ca…

obstetricsmidwiferydiagnosticcommunication
VICmental health2017-02-07

Finding into death of Esther Ng Kit Ching

53y · Female·Hypoxic brain injury due to hanging

A 53-year-old woman with severe depression, anxiety, and recent suicide attempt died by hanging in a psychiatric hospital's low-dependency…

psychiatrycommunicationdelaymirtazapine
VICmental health2017-05-18

Finding into death of Derek Hamilton

46y · Male·Cerebral ischaemia secondary to compression of the neck in circumstances of hang…

Derek Hamilton, a 46-year-old involuntary psychiatric patient with cluster B personality disorder and recurrent depression, died from cerebral ischaemia secondary to hanging while an inpatient at Northern Hospital Psychi…

psychiatryintensive caresystemcommunicationmirtazapine
WAhospital2024-05-06

Inquest into the Death of Devan Beau GINBEY

20y · Male·Hypoxic brain injury following ligature compression of the neck (hanging)

…issed due to staff preoccupation. He subsequently died by hanging. The coroner identified systemic issues: severe mental health bed shortage, absence of appropriate mental health observation areas, inadequate ED environm…

emergency medicinepsychiatrysystemdelay
VICcommunity2026-05-07

Finding into death of Elizabeth Susan Edwina Ferris

44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…

…iple substances (opioids, benzodiazepines, methamphetamine, and others). She was resuscitated but suffered severe irreversible brain injury and died 16 days later. The coroner found no direct causal link between her deat…

psychiatryintensive carediagnosticcommunicationheroin
SAmental health2025-04-17

Coroner's Finding: Furlan, Mark John & Miller, Richard John

50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…

Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…

psychiatryemergency medicinediagnosticcommunicationescitalopram
ACTmental health2021-03-04

Inquest into the deaths of ANTHONY LEIGH BEARHAM, NICOLA JOY FISHER, CHRISTINE BELLE DOUCH andKEN ALEXANDER LUCAS

Bearham: hypoxic brain injury from hanging; Fisher: asphyxiation from hanging by…

Four inpatient suicides occurred at The Canberra Hospital mental health units between January 2015 and November 2016: three by hanging and one by jumping. The coroner found systemic failures including inadequate ligature…

psychiatryemergency medicinediagnosticsystem
QLDaged care2019-06-17

Ms SME - Non-inquest findings

86y · Female·subdural haemorrhage due to or as a consequence of a fall

Ms SME, an 86-year-old resident at a Blue Care nursing home, suffered a fatal subdural haemorrhage following a fall from bed during a sponge bath on 18 January 2016. She died on 21 January 2016. Clinical lessons include:…

geriatric medicineemergency medicineproceduralsystemoxycodone
VICcommunity2016-08-18

Finding into death of Paul Daniel Rayudu

22y · Male·hypoxic ischaemic encephalopathy in the setting of immersion (drowning)

…he drop-off zone and both became submerged. Although patrons and staff performed prompt CPR, Paul suffered severe hypoxic-ischaemic brain injury and died 6 days later. The coroner found the death preventable. Key prevent…

communicationsystem
SAhospital2014-11-14

Coroner's Finding: KEY George Darcy

0y · Male·Perinatal hypoxic ischaemic encephalopathy with severe diffuse cortical necrosis…

George Darcy Key, an 8-day-old neonate, died from perinatal hypoxic ischaemic encephalopathy following labour complicated by excessive syntocinon-induced contractions and delayed obstetric intervention. The infant was de…

obstetricsanaesthesiadiagnosticcommunicationoxytocin

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