Coronial

450 results for emergency procedures training

QLD2005-10-14

Liddington, Craig; Eva, Stewart; Carpenter, Andrew

31y · Male·Injuries sustained as a consequence of helicopter crash into water

Three emergency service personnel—pilot Andrew Carpenter (31), paramedic Craig Liddington (31), and crewman Stewart Eva …

emergency medicineaviation medicinediagnosticcommunication
NSW2022-10-06

Inquest into the death of ZA

Male·Fentanyl toxicity, with aspiration pneumonia as a significant contributing condi…

A man (ZA) died from fentanyl toxicity in custody at Shortland Correctional Centre after his cellmate, who had brought fentanyl into the prison by concealing it in his rectum, shared it with him. Both men snorted the pow…

forensic medicineemergency medicinesystemdelayfentanyl
NThome2021-11-09

Inquest into the death of Holly Davidson

38y · Female·Subdural haemorrhage in the context of chronic alcoholism due to post-traumatic …

…view of incidents, and lack of crime scene protocols. Enhanced oversight, information coordination, staff training in coercive control identification, and establishment of risk assessment tools are essential.

emergency medicinepsychiatrydiagnosticsystemparacetamol/codeine/doxylamine
VIC2018-11-13

Finding into death of Morgan Patrick MCCabe

42y · Male·Drowning

…ck, the combination of inadequate planning, insufficient staffing, poor risk analysis, and lack of clear emergency protocols contributed to a preventable death.

emergency medicinesystemproceduralfluoxetine
QLDhospital2017-06-22

PS - Non-inquest findings

68y · Female·Coronary heart disease

A 68-year-old woman with diabetes, hypertension, hypercholesterolaemia, COPD and chronic renal failure presented with chest pain and dyspnoea. She was admitted with suspected congestive cardiac failure; troponins were no…

cardiologyemergency medicinediagnosticcommunicationfurosemide
WAhospital- 27 May 2014

Inquest into the Death of Julissa Teresa GILBERT

57y · Female·Intra-abdominal Haemorrhage following Appendectomy, with contributing factor of …

A 57-year-old woman with COAD, hypertension, and unrecognized severe coronary atherosclerosis presented with appendicitis. Surgery was performed by an unsupervised surgeon operating on friable tissues with limited visibi…

anaesthesiasurgerydiagnosticcommunicationaramine
TAS2022-04-29

Coroner's Finding: Lavoipierre, Andre Marc

41y · Male·exsanguination (hypovolemic shock complicating acute blood loss) due to fistula …

… despite fall, blood, dizziness, and hypotension signs; relied on late after-hours GP service instead of emergency ambulance. The case highlights importance of recognising hypovolemic shock presenting as dizziness, fail…

psychiatrygeneral practicecommunicationdelayfluoxetine
NSWhospital2018-11-23

BURTON-HO Anqelique File 2015-235464 Findings given by Mag Grahame DSC on 23-11-2018

12y · Female·Cardio-respiratory failure due to aspiration pneumonia

…ially preventable with earlier retrieval, and recommended improved escalation protocols, clinical review procedures with fresh eyes, and stronger REACH program implementation.

anaesthesiaemergency medicinediagnosticdelay
VICaged care2018-12-10

Finding into death of Doris Clare Spratling

93y · Female·Haemothorax complicating rib fractures sustained in a fall

… but the Flexi-link safety latch had considerable play and lacked additional safety features. While staff training and qualifications were adequate, the equipment design had inherent vulnerabilities. The coroner found no…

geriatric medicineemergency medicinesystem
WAcommunity2010-04-15

Inquest into the Death of Lynch

20y · Female·food-induced anaphylaxis, likely to peanut allergen

…Bay Nursing Post under telephone guidance from Dr D. at Exmouth Hospital 150km away. Despite appropriate emergency treatment including oxygen, nebulised and intramuscular adrenaline, intravenous hydrocortisone, and an a…

emergency medicinegeneral practicedelaydiagnosticadrenaline
QLDhospital2009-12-08

Congoo, Sharon Faye

40y · Female·Bacterial septicaemia from an unknown organism

Sharon Faye Congoo died from overwhelming bacterial septicaemia of unknown origin at age 40. She presented to Mareeba Hospital (a small rural facility) on three occasions with non-specific viral-like symptoms and leg pai…

emergency medicineintensive caresystemcommunication
VICmental health2017-06-29

Finding into death of Peter James Nolan

75y · Male·Hanging

Peter Nolan, a 75-year-old man with depression, chronic pain, alcohol dependence, and recent suicide attempts, died by hanging in an aged psychiatric mental health unit. He was admitted to Broadmeadows Aged Psychiatric M…

psychiatrygeriatric medicinesystemcommunicationsertraline
VIChome2021-12-06

Finding into death of Daniel Charles Richards

48y · Male·Ischaemic heart disease complicating restraint of an acutely agitated male

…uming underlying cardiovascular disease in those with mental illness; (3) de-escalation and communication training for police (PRIME training); and (4) paramedic-led emergency response models. The coroner found actions o…

psychiatryemergency medicinesystemcommunication
VIC2011-04-04

Finding into death of Wingeel Plains Fire

Fire outbreak caused by sparks and molten metal from defective wagon air brake s…

… contributed. The train crew, aware from the prior incident that brake failure was likely, had attempted emergency measures but these proved unsuccessful. The coroner emphasised that rural properties faced continuous fi…

systemdelay
NSW2018-07-13

Inquest into the death of Fenika Junior Tautuliu Fenika (Junior Fenika)

24y · Male·Massive blood loss caused by incised wounds of left upper extremity

A 24-year-old man with schizophrenia and psychotic symptoms died from massive blood loss after self-inflicted wrist lacerations in prison custody. He called for help twice via the cell alarm system at 9:17pm and 9:23pm, …

psychiatryemergency medicinecommunicationsystemamisulpride
WAhome2018-03-22

Inquest into the Death of Aileen Helen QUARTERMAINE

60y · Female·effects of fire in a woman with alcohol effect

…t may have enabled appropriate assessment and treatment. Both agencies subsequently implemented improved procedures for information gathering, escalation, and coordination between police and mental health services in reg…

psychiatryemergency medicinecommunicationdiagnosticpaliperidone
QLD2021-05-24

Ahquee, Dylon James

19y · Male·Hanging

…clinical lessons focus on systematic information transfer between youth and adult systems, risk flagging procedures, and ensuring appropriate cell placement for identified at-risk individuals, there was insufficient earl…

correctional healthpsychologydiagnosticsystem
NSWhospital2021-12-15

Inquest into the death of Bailey Mackander

20y · Male·Multiple injuries from fall from height

…therapeutic responses. Better mental health support, least-restrictive placement options, and proper RIT procedures could have prevented this tragedy. Bailey's impulsive escape resulted from his desperation to avoid retu…

psychiatrypsychologydiagnosticcommunicationmethamphetamine
VIChome2025-12-19

Finding into death of Narisha Faye Cash

41y · Female·Combined Drug Toxicity (ethanol and benzodiazepine)

… died on 26 March 2020 from combined drug toxicity (ethanol and benzodiazepines) following an inadequate emergency services response to her mental health crisis. She called 000 expressing suicidal intent and reported co…

emergency medicinepsychiatrysystemcommunicationalcohol
NSWprison2021-11-19

Inquest into the death of Danny Whitton

25y · Male·Multiple organ failure due to acute paracetamol poisoning

Danny Whitton, a 25-year-old Aboriginal prisoner at Junee Correctional Centre, died from acute paracetamol toxicity causing multi-organ failure. He presented to the prison medical clinic on 5 November 2015 with vomiting …

emergency medicinetoxicologydiagnosticcommunicationparacetamol
116171823

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.