329 results for “delivery”
78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…
78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). T…
60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…
… and inadequate clinical oversight of a junior doctor responsible for 1150 inmates. The coroner found the delivery of healthcare was 'chaotic' due to severe understaffing, with one GP managing a population that contractu…
0y · Female·Organ failure caused by not receiving enough oxygen during labour (intrapartum h…
… midwives counted in numbers, and unclear care planning. Earlier recognition of CTG changes and expedited delivery could potentially have prevented death.
25y · Female·inhalation of petrol (hydrocarbon inhalation)
This is a complex coroner's inquest into three Aboriginal deaths from petrol inhalation on the Anangu Pitjantjatjara Lands. Kunmanara Hunt, age 25, died on 27 January 2001 after inhaling petrol fumes while lying face-dow…
31y · Male·hanging
B W, aged 31, died by hanging following emergency police removal of his daughter from his care under the Care and Protection Act. The removal occurred in early hours of 17 April 2020 during COVID-19 lockdown. B W had lon…
9y · Male·asthma - acute episode of asthma which became increasingly resistant to Ventolin
…was clinically appropriate based on examination findings, but there were deficiencies in asthma education delivery and assessment. Hunter deteriorated at home on 6 January and died of acute asthma resistant to Ventolin. …
Unknown·Multiple; Kunmanara Ward: neck compression due to hanging; Kunmanara Ken: exposu…
Four Aboriginal individuals died on Anangu Pitjantjatjara Lands between May 2003 and March 2004. Ward (19) and Ryan (25) died by hanging with evidence of petrol intoxication. Ken (35) died from exposure after wandering a…
62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (su…
A 62-year-old man died from intraoperative haemorrhage during surgery for a renal tumour initially diagnosed as benign anastomosing haemangioma on biopsy but found at autopsy to be metastatic clear cell renal cell carcin…
26y · Male·ligature compression of the neck (hanging)
… supervision and care fell below appropriate standards due to resource limitations and fragmented service delivery.
36y · Male·Hanging (Mr Sharma); Homicide by smothering/suffocation or chloroform exposure (…
Nilesh Sharma, a 36-year-old Fiji Indian man, killed his wife Preetika, son Divesh (5 years old), and daughter Divya (3 years old) between 28-29 April 2012, then died by hanging. Evidence suggests he exposed them to chlo…
24y · Female·hypoxic brain damage due to cardiac arrest due to hanging
Jodie Maree Davis, aged 24, died by suicide in Townsville Correctional Centre in May 2002. She had a long history of self-harm dating from age 15, including multiple suicide attempts, and was assessed as high suicide ris…
32y · Male·Asphyxia in a man with Friedreich's Ataxia due to positional asphyxia; unable to…
Leslie Troy Ovens, a 32-year-old man with progressive Friedreich's Ataxia, died from positional asphyxia after falling from his wheelchair. He had deteriorated significantly after hospitalisation in June 2013 and was wea…
3y · Female·Homicide by chloroform exposure and/or smothering by father
Divya Sharma, age 3, died in April 2012 in Glen Waverley, Victoria, as part of a family homicide-suicide perpetrated by her father. The coroner found she was likely killed by chloroform exposure and smothering between 28…
44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…
…ilures were not found causative of death, the coroner highlighted systemic issues in custodial healthcare delivery and urged adequate funding and staffing.
56y · Female·multiple blunt force injuries deliberately inflicted
Gayle Elizabeth Woodford, a 56-year-old registered nurse working in Fregon, APY Lands, was abducted and murdered on 23 March 2016 by Dudley Davey, who had a long history of violent sexual offences dating back to age 14. …
42y · Male·ligature compression of the neck (hanging)
Wayne Larder, a 42-year-old man with depression, suicidal ideation, and substance use disorder, died by hanging in Hakea Prison on 22 February 2021. Critical failures in suicide risk management included: (1) mental healt…
43y · Female·suffocation
Ms K, aged 43, was killed by her husband through suffocation on 7 March 2017 after years of coercive control, physical violence, and emotional abuse. A critical police response on 17 August 2016 when Ms K reported car va…
22y · Female·staphylococcal septicaemia and pneumonia complicating osteomyelitis of a right 1…
Julieka Dhu, a 22-year-old Aboriginal woman, died on 4 August 2014 from staphylococcal septicaemia and pneumonia complicating osteomyelitis of a rib fracture sustained in April 2014. She was detained in police custody on…
4y · Female·closed head injury with contributing extensive subcutaneous and intramuscular ha…
Chloe Lee Valentine, aged 4 years 5 months, died on 20 January 2012 from closed head injury with extensive subcutaneous and intramuscular haemorrhage. The fatal injuries resulted from repeated trauma inflicted during a p…
35y · Male·self-inflicted gunshot wound to the head
Ralph Donald, aged 35, died by suicide after attempting to kill his ex-partner Eileen Gibbons on 3 October 2023 in Milner, NT. The death occurred in context of escalating coercive control including verbal abuse, property…
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