Coronial

332 results for emergency patient transfer

WAhospital

Inquest into the death of Amanda Dana TAUAI

21y · Female·Multiple organ failure due to undefined sepsis (toxic shock syndrome)

…ture results showing elevated neutrophils (suggesting bacterial infection) were not available until after transfer. Expert review suggests earlier blood cultures and empirical antibiotics at 3am on 15 March (after vital …

general practiceemergency medicinediagnosticcommunicationmetoclopramide
VIChospital2025-08-04

Finding into death of Winifred Jean Carpenter

82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…

Winifred Carpenter, 82, died 11 days after a right hemicolectomy for colon cancer from peritonitis due to anastomotic leak. Critical failures occurred on discharge day (10 March 2023): clinicians did not recognize her de…

general surgerycolorectal surgerydiagnosticcommunication
NSWmental health2019-11-22

Inquest into the death of David Dungay

29y · Male·cardiac arrhythmia

…rily called the Immediate Action Team (IAT) to move him to a camera cell, despite no security or medical emergency existing. During the forceful cell transfer, David was repeatedly restrained in the prone position, comp…

psychiatryemergency medicineproceduralcommunicationmidazolam
QLDcommunity2016-04-20

Newport, Glenn Richard

38y · Male·cardiac arrest precipitated by dilutional hyponatraemia

…ncrete formwork project in rural Queensland. He developed symptoms of heat injury at the worksite and was transferred to an on-site clinic where paramedics managed his rapid respiration with oral fluids but failed to esc…

occupational and environmental healthparamedicinediagnosticcommunication
NSWhospital2024-05-10

Inquest into the death of Finlay Browne

16y · Male·mid-gut volvulus and bowel obstruction, leading to ischaemic bowel and related c…

…ing, and imaging showing caecal malrotation with volvulus—his condition was not recognised as a surgical emergency until late evening. Critical delays in senior physician oversight, delayed CT imaging interpretation, an…

emergency medicinesurgerydiagnosticcommunication
NSW2011-07-01

Coroner's Finding: Michael Peter Magro

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

…l 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. Despite appropr…

correctional healthgeneral practicediagnosticcommunicationmethadone
VICcommunity2022-12-01

Finding into death of Gabriel Messo

30y · Male·Gunshot wounds to the chest

…es; information handover between mental health and police must be thorough and comprehensive; police s351 transfers require adequate clinical assessment; Emergency Department registrars should have access to comprehensiv…

psychiatryemergency medicinecommunicationsystem
NSW2019-07-05

Inquest into the death of Rebecca Maher

36y · Female·respiratory depression after loss of consciousness caused by mixed drug toxicity…

Rebecca Maher, a 36-year-old Aboriginal woman, died from respiratory depression caused by mixed drug toxicity (high levels of Alprazolam and Methadone) while detained as an intoxicated person at Maitland police station. …

general practicepharmacydiagnosticmedicationalprazolam
NSWhospital2019-05-14

Inquest into the death of Shaun BELL

4y · Male·Peritoneal sepsis caused by a perforated duodenal ulcer

A 4-year-old boy with significant global developmental delay and non-verbal communication died from peritoneal sepsis caused by a perforated duodenal ulcer. Presentation included lethargy, poor oral intake, low haemoglob…

emergency medicinepaediatricsdiagnosticcommunication
VIC2022-06-03

Finding into death of Micky Craig Revera

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

Micky Craig Revera, a 40-year-old man with chronic heroin addiction, died in Melbourne Assessment Prison on 18 February 2019 from unascertained causes. He was arrested on 12 February after erratic driving, underwent poli…

emergency medicineforensic medicinediagnosticcommunicationheroin
SAhome2012-06-06

Coroner's Finding: Home Birthing - SPENCER-KOCH Tate and HOBBS Jahli Jean and KAVANAGH Tully Oliver

Tate Spencer-Koch: intrapartum hypoxia due to shoulder dystocia; Jahli Hobbs: in…

Three neonates died following complications during planned homebirths attended by midwife Lisa Barrett. Tate Spencer-Koch (4790g, macrosomic) died from intrapartum hypoxia caused by shoulder dystocia; delivery was obstru…

obstetricsmidwiferydiagnosticcommunication
QLDcommunity2006-12-15

Barlow, Charles Edward; Lusk, Patrick Douglas; Baggott, Emily Jane

asphyxia sequential to hanging (all three cases); Charles Barlow: schizophrenia …

…ueensland mental health services. Charles Barlow (36, Aboriginal) was denied admission despite requesting transfer to Cairns Base Hospital Mental Health Unit; discharged from Yarrabah hospital to die by suicide hours lat…

psychiatrygeneral practicediagnosticcommunicationflupenthixol

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