Coronial

450 results for emergency procedures training

QLDhospital2011-11-04

Smith, Darryl Robert

34y · Male·Air embolism and severe haemorrhage due to perforation of the right subclavian v…

Darryl Smith, aged 34, died following emergency surgery for a fractured clavicle at Sunnybank Private Hospital. During the final drilling of the sixth s…

orthopaedic surgeryanaesthesiaproceduraldelayadrenaline
NThospital2018-01-11

Inquest into the death of Addison Anthony

35y · Male·Active rheumatic pancarditis complicated by pulmonary arterial hypertension, pne…

A 35-year-old Aboriginal man died from rheumatic pancarditis complicated by pulmonary hypertension, pneumonia and unspecified connective tissue disease. He had presented repeatedly to Katherine Hospital with symptoms sug…

emergency medicineintensive carecommunicationdiagnosticdicloxacillin
NSWaged care2022-06-24

Inquest into the death of Thomas FULCHER

70y · Male·hypovolaemic shock due to the consequences of fractured femur

…are essential. Northcott subsequently implemented comprehensive reforms including policy revisions, staff training, improved rostering, and a 'no assumptions' campaign.

orthopaedic surgeryemergency medicinediagnosticcommunication
QLDhospital2025-03-31

Inquest into the death of Jamie Brian Campbell

43y · Male·Hypoxic ischaemic encephalopathy, due to or as consequence of, cardiac arrest of…

…d junior team members. The case highlights the critical importance of recognizing restraint as a medical emergency, performing baseline vital signs, and identifying sympathomimetic toxicity.

emergency medicinetoxicologydiagnosticmedicationmethamphetamine
VIC2024-02-19

Finding into death of John Robert Gregg

52y · Male·Hypoxic ischaemic encephalopathy and multi-organ failure due to coronary artery …

John Gregg, 52, died from hypoxic ischaemic encephalopathy and multi-organ failure following cardiac arrest during a recreational scuba dive. Autopsy revealed severe coronary artery atherosclerosis and borderline cardiom…

emergency medicineintensive carediagnosticcommunication
VIC2010-02-12

Finding into death of Wesley Robert Jennings

42y · Male·incised wound to the neck

Wesley Robert Jennings, a 42-year-old male with long-standing depression, anxiety, hepatitis C and substance use history, died by suicide by incised neck wound whilst on remand in prison. The coroner found no demonstrabl…

psychiatrypsychologycommunicationsystemcitalopram
ACT2009-10-29

Inquest Into The Death Of Kaled Kanj

2y · Male·drowning (immersion)

…ding pool design, lifeguard deployment, signage, supervision ratios, risk assessment protocols, and staff training to enhance child safety at public pools.

emergency medicineintensive care
VIChospital2019-02-11

Finding into death of Stephen John Caruana

48y · Male·Hypoxic ischaemic encephalopathy complicating upper cervical spine and cord inju…

… tree trimming and removal is hazardous work requiring appropriate risk control measures, adequate worker training, and emergency procedures. WorkSafe Victoria's guidance lacked specific information on falling trees and …

emergency medicineintensive caremidazolam
TAShome2017-06-26

Coroner's Finding: Johnstone, BJay

0y · Male·Traumatic head injury

BJay Adam Johnstone, 45 days old, died from severe traumatic head injury inflicted by his father Simon Johnstone in a household environment. BJay suffered multiple episodes of violence including head trauma, rib fracture…

paediatricsemergency medicinediagnosticsystemcannabis
TAS2019-03-27

Coroner's Finding: Close, Terrence Findings

62y · Male·blunt trauma of chest and abdomen

…mphasized that multiple preventable factors—poor signage placement, lack of physical barriers, inadequate training, and failure to comply with Australian Standard 1742.3-2009—created an unsafe environment where the traff…

emergency medicinetrauma surgerysystemcommunication
WAhospital2010-03-03

Inquest into the Death of McLevie

38y · Female·Streptococcus Group A Septicaemia (Post Partum-Puerperal Sepsis)

…a registrar not visiting the patient or reviewing notes; and failure to recognise and respond to medical emergency criteria. The coroner found this a preventable death and made eight recommendations including mandatory …

obstetricsmidwiferydiagnosticcommunicationparacetamol/codeine
VICcommunity2014-06-30

Finding into death of Lewis John Muratori

50y · Male·Multiple injuries as a result of being struck by a train

A 50-year-old ICU nurse at Cabrini Hospital died by suicide by stepping in front of a train after experiencing a cascade of adverse events. In October 2009, he attended work while intoxicated following personal stress, l…

psychiatryemergency medicinecommunicationsystemaurorix
SAhospital2009-07-30

Coroner's Finding: BRUNT Sidney

65y · Male·acute right subdural haematoma

Sidney Brunt, aged 65, died from an acute right subdural haematoma caused by excessive, unmonitored anticoagulation with warfarin. His general practitioner, Dr A., prescribed warfarin for atrial fibrillation but failed t…

general practiceemergency medicinemedicationcommunicationwarfarin
NSWhospital2014-12-19

Inquest into the death of JX

32y · Male·multiple injuries sustained in a fall from height

…plete required triage documentation or alert the receiving hospital—breaching mandatory policies. At the Emergency Department, although appropriately triaged as category 3, the patient was not reassessed as the 30-minut…

psychiatrypsychologycommunicationsystemvenlafaxine
NTcommunity2001-11-02

Inquest into the death of Nathan Wade Brooks

20y · Male·Electrocution resulting in cardiac arrhythmia and cardiac arrest

…. The coroner noted that proper industry standards, site coordination, hazard identification, and safety procedures could have prevented this death. Key lessons include the need for mandatory scaffold compliance, site-wi…

occupational and environmental healthoccupational therapysystemprocedural
NSWhospital2017-06-06

Inquest into the death of Helen Ashburn

46y · Female·Prolonged effects and complications of a head injury, with upper airway obstruct…

…ory notification to police for suspected domestic violence was not applied; (3) medical staff at a rural emergency department lacked awareness of DV screening protocols and reporting obligations; (4) electronic systems …

emergency medicineneurosurgerycommunicationdiagnostic
VICaged care2020-10-22

Finding into death of Phillip Harry Parker

61y · Male·Pneumonia

A 61-year-old man with significant medical complexity including acquired brain injury, bronchiectasis, pulmonary fibrosis, and dysphagia died from pneumonia 26 days after receiving another resident's slow-release opioid …

geriatric medicineemergency medicinemedicationsystemtapentadol sr
NSWhospital2026-02-26

Inquest into the death of Jeremy Webb

16y · Male·Anaphylaxis due to mammalian meat allergy after tick bite, causing an acute exac…

Jeremy Webb, 16, died from anaphylaxis due to mammalian meat allergy (tick-induced) which triggered status asthmaticus. He had experienced red meat reactions since age 10 and a severe respiratory event in April 2021 that…

emergency medicineallergy and immunologydiagnosticcommunicationadrenaline
QLD2020-11-16

Haynes, Barry

58y · Male·Metastatic non-small cell lung carcinoma

Barry Haynes, a 58-year-old Aboriginal man, died of metastatic non-small cell lung carcinoma while on remand in custody. He had stage 4 lung cancer with brain metastases diagnosed in November 2016, shortly before his arr…

oncologypalliative caresystemdelay
NSW1979-09-03

Inquiry into the fire and deaths at Luna Park

Unknown·Carbon monoxide poisoning and burns (or burns only in one case), accidentally su…

… coroner identified critical safety failures: absence of the required internal patrol attendant, lack of emergency lighting and hose reel systems (mandatory upgrades not yet completed), poorly marked or hidden escape ex…

systemdelay
115161723

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