Coronial

538 results for “observation”

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NSWcustodial setting (correctional facility) with death at hospital2025-07-23

Inquest into the death of James Cunneen

60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…

James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…

general practiceinfectious diseasesdiagnosticmedicationpantoprazole
TASmental health2019-01-04

Coroner's Finding: Roberts, Nigel Douglas

55y · Male·Cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and…

…ter, insufficient respiratory rate monitoring, failure to exclude delirium as cause of agitation, vague observation orders, and absence of specialist respiratory input. The coroner found the death was otherwise preventa…

psychiatryemergency medicinemedicationdiagnosticclozapine
QLDhospital2008-09-12

Neville, Elise Susannah

10y · Female·Head injuries due to fall from a bunk bed

Elise Neville, aged 10, fell from a non-compliant bunk bed and sustained a head injury. At her first ED presentation to Caloundra Hospital at 3:25am, Dr D.—a junior house officer 19 hours into a 24-hour shift—failed to p…

emergency medicineneurosurgerydiagnosticcommunicationmannitol
VIChospital2026-05-19

Finding into death of Edward Timothy Peterson

25y · Male·Head injury sustained on impact with a train

…as appropriate: medications were adjusted following prior non-compliance, regular reviews occurred, and observation levels were modified based on clinical improvement. On 22 February 2021, after reassurance about discha…

psychiatrysystempaliperidone
VIC2013-08-19

Finding into death of TH

2y · Female·Blunt force injury to the abdomen

…hargy, pallor, and apparent illness requires immediate emergency assessment and transfer, not expectant observation at home or in public places.

paediatric surgeryemergency medicinedelaysystem
SAaged care2020-07-09

Coroner's Finding: HANSLOW Walter Robert

75y · Male·bilateral subdural haematoma due to fall

…ursing home and hospital was appropriate and lawful. Clinical lessons include the importance of careful observation and early recognition of deterioration post-fall in elderly patients on anticoagulation or with bleedin…

geriatric medicineemergency medicinedelay
VIC2022-06-03

Finding into death of Micky Craig Revera

40y · Male·Unascertained; opioid withdrawal-related seizure or cardiac arrhythmia could not…

…ntation of injuries and mechanism is essential; mobility assessment should accompany trauma evaluation; observations of at-risk prisoners must be thorough and properly documented.

emergency medicineforensic medicinediagnosticcommunicationheroin
NTcommunity2007-06-21

Inquest into the death of Zachariah Foster

30y · Male·Blunt Head Injury resulting from a Motor Vehicle Collision

Zachariah Foster, a 30-year-old male, died from blunt head injury sustained when struck by a police vehicle on the Ali Curing Access Road at night. He was walking along the road in a prone position after consuming alcoho…

alcohol
TASaged care2023-11-20

Coroner's Finding: Gray, Laurence Keith

96y · Male·Traumatic closed head injuries sustained in a fall

A 96-year-old man with cognitive impairment and previous traumatic brain injury from a 2021 fall was admitted to residential aged care on 16 February 2022. He had a minor slip from his chair on admission day without inju…

geriatric medicinegeneral practice
VIC2020-04-06

Finding into death of Darren Brandon

51y · Male·hypoxic-ischemic encephalopathy due to hanging

…uld have been assigned a higher suicide risk rating and placed in a suicide-prevention cell with hourly observation, not in a cell with ligature points. Systems failures in information sharing between agencies, police f…

psychiatryforensic medicinecommunicationsystemoxycodone
WAhospital2005-09

Inquest into the Death of Maria Donatelli

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

…aged conservatively with a provisional diagnosis of pancreatitis or bowel obstruction. During overnight observation in the surgical ward, her clinical condition deteriorated markedly from approximately 22:00 hours on 6 …

general surgeryemergency medicinediagnosticcommunicationtramadol
SAhospital2010-06-03

Coroner's Finding: PROMNITZ Aileen Dawn

79y · Female·Sepsis due to urinary tract infection with Group B streptococci

…mortality by 20-30%. Subsequently, improvements were implemented including dedicated waiting room nurse observation and a formal over-capacity Code E policy.

emergency medicineinfectious diseasesdelaysystem
WAhospitalAugust 2023

Inquest into the Death of Justin DOBSON

46y · Male·sepsis following haemorrhoidectomy

… (Mr Filgate) when Mr Dobson was not discharged as expected; failure to make a MET call at 3:00 pm when observations met criteria; and failure to provide a handover to the after-hours doctor. Earlier recognition and tra…

general surgerycolorectal surgerydiagnosticcommunicationmetronidazole
SAhospital2009-12-09

Coroner's Finding: VELKOS Basile

39y · Male·Multi organ failure complicating acute paraquat and diquat toxicity

A 39-year-old man with depression and alcohol misuse died from multi-organ failure following acute paraquat and diquat toxicity. He ingested herbicide stored in a Coca-Cola bottle on 10 June 2006, arriving at hospital si…

emergency medicinetoxicologyparaquat
TAShome2016-07-14

Coroner's Finding: Bedford, Sidney

83y · Male·Acute subdural haemorrhage following a fall

…all (3-4 mm) acute subdural haematoma in the right temporo-frontal region. The patient was admitted for observation and surgical repair of facial wounds. On 31 October, Mr Bedford deteriorated with confusion and loss of…

emergency medicineradiologydiagnosticwarfarin
QLDaged care2011-05-31

Frost, Margery

85y · Female·Coronary atherosclerosis with other significant factors being acute bronchitis, …

Margery Frost, an 85-year-old resident at a newly-opened nursing home, died from coronary atherosclerosis. She was found on the floor with her head against a lifting hoist stored in her room, though autopsy confirmed the…

geriatric medicinesystem
WA2020-11-28

Inquest into the Death of Wayne Thomas LARDER

42y · Male·ligature compression of the neck (hanging)

…ality were not communicated to prison staff; (5) inadequate ARMS supervision with only one face-to-face observation in 18 hours; (6) only six safe cells at a facility housing 900+ prisoners, many with mental health need…

psychiatrypsychologydiagnosticsystemmethamphetamine
SA2019-05-23

Coroner's Finding: HARRIS Philip Michael

30y · Male·exsanguination due to division of left brachial artery

…tal health presentations. Despite being identified as high-risk on admission and placed under intensive observation, he spontaneously became agitated and cut himself without warning. Prison officers responded appropriat…

psychiatryemergency medicinecarbamazepine
VICmental health2021-01-22

Finding into death of Mr LY

42y · Male·Multiple injuries sustained in a fall from a height

Mr LY, a 42-year-old compulsory inpatient with extensive mental health history, died by suicide when he jumped from the Belford Road overpass during approved unescorted leave. Key clinical events included a concerning ps…

psychiatry
SAmental health2013-09-19

Coroner's Finding: SZCZEPANIAK Eugeniusz

75y · Male·neck compression due to hanging

…d evidence of suicidal ideation despite a remote history of suicidal thoughts. The coroner found hourly observations were appropriate given absence of perceived self-harm risk, though protocol suggested 15-minute observ…

psychiatrygeriatric medicinedocumentationsystemrisperidone
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