Coronial

373 results for life support

QLDcommunity2024-11-04

Inquest into the death of Damon Paul William Savage

27y · Male·Multiple gunshot wounds

…omestic violence. Mental health services had assessed him multiple times with recommendations for ongoing support, which he declined or disengaged from. Critical clinical lessons include: early identification of escalat…

psychiatryemergency medicinecommunicationsystemmethamphetamine
WAcommunity2004-10-08

Inquest into the Death of Morgan

31y · Male·Lymphocytic Myocarditis in association with Acute Pericarditis (viral origin, ae…

Norman John Morgan, aged 31, died at Carnarvon Airport on 21 December 2001 from lymphocytic myocarditis with acute pericarditis (viral origin). He presented to Carnarvon Regional Hospital on 20 December with chest and sh…

general medicineemergency medicinecommunicationsystemceftriaxone
QLDhospitalNew2026-06-09

Inquest into the death of Rosemarie Campbell

62y · Female·Acute bacterial peritonitis and pneumonia

Rosemarie Campbell, 62, died 27 February 2022 from acute bacterial peritonitis and pneumonia following a Roux-en-Y gastric bypass at Wesley Hospital. Pre-operative failures: The surgeon inadequately investigated her refl…

bariatric surgeryanaesthesiadiagnosticproceduralesomeprazole
QLDhospital2013-10-28

Loveday, Marcia Joy

74y · Female·Cardio-renal failure due to gangrene of calculous gallbladder, with significant …

An elderly woman with a documented penicillin allergy, wearing a MedicAlert bracelet, presented to emergency with respiratory distress and chest pain. She was administered intravenous Ampicillin without allergy verificat…

emergency medicineintensive carediagnosticmedicationampicillin
VIChospital2026-04-28

Finding into death of Ronald William Beaumont

74y · Male·Acute myocardial infarction complicated by multiple organ failure

Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…

cardiologyorthopaedic surgerymedicationcommunicationaspirin
QLDhome2014-11-17

Beutel, Noelene Marie

36y · Female·traumatic head injuries from multiple assaults perpetrated by domestic violence …

Noelene Beutel died from severe head injuries inflicted by her domestic violence partner in 2011. Although she had engaged with police, GPs, hospitals, and domestic violence agencies in the six months before her death, s…

general practiceemergency medicinecommunicationsystem
NSWaged care2025-01-24

Inquest into the deaths at Newmarch House

Unknown·COVID-19 infection with various comorbidities as contributing factors

This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…

geriatric medicineinfectious diseasessystemdiagnosticmorphine
NSWhospitalPodcast2023-03-03

Inquest into the death of Bradley HOPE

16y · Male·cardiac arrhythmia or hypoxia in the setting of hydrocarbon inhalation

Bradley Hope, 16, died from cardiac arrhythmia or hypoxia following inhalation of hydrocarbon propellants from an aerosol deodorant purchased at a supermarket self-checkout. After engaging in volatile substance use with …

emergency medicinetoxicologydelaybutane
VIC2025-11-12

Finding into death of Wendy Ann McCabe

40y · Female·hypoxic ischaemic encephalopathy due to ligature compression of the neck

…d DRA. By 7:13pm she had asphyxiated using the blanket. Resuscitation efforts continued and she remained on life support briefly but died 3 December 2021. The coroner found multiple failures: delayed DRA completion, inap…

correctional healthemergency medicineproceduralcommunicationmethadone
VIChome2026-03-19

Finding into death of Catherine Alison Lynch

41y · Female·Mixed drug toxicity (alprazolam, clonazepam, diazepam, methadone, metoclopramide…

…of their responsibility; family violence is a known risk factor for suicide; and consistent messaging and support about family violence across all treating clinicians may have altered Catherine's experience. The coroner…

psychiatrypsychologycommunicationsystemalprazolam
QLDhospital2010-10-18

Little Gungallida Girl

4y · Female·aspiration of vomitus and its treatment due to rheumatic carditis against a back…

A 4-year-old Aboriginal girl from Doomadgee died on 23 July 2009 from aspiration of vomitus complicating rheumatic carditis with concurrent viral respiratory tract infection. She presented with fever and cough on 19, 21,…

emergency medicinepaediatricsparacetamol
NSWcustody2024-08-08

Inquest into the death of Phillip Boney

43y · Male·hanging

…ventable risk factors were not mitigated. Key learnings include the importance of communicating significant life events between correctional facilities, considering First Nations inmates' family and cultural connections …

psychiatrygeneral practicecommunicationsystemmirtazapine
WAprison

Inquest into the Death of Ian HEAD

74y · Male·cardiac arrhythmia in an elderly man with chronic obstructive pulmonary disease …

…ntifying unresponsive prisoners during welfare checks. The coroner noted missed opportunities for earlier support but concluded death was unlikely preventable given multiple comorbidities and non-reporting of symptoms.

general practiceemergency medicinecommunicationsystemparacetamol
VIChospital2018-06-14

Finding into death of Ian John Gilbert

77y · Male·Complications of methotrexate toxicity in a man with chronic renal impairment, c…

A 77-year-old man with chronic kidney disease, COPD, and mild cardiac failure died from methotrexate toxicity after a GP prescribed it at an inappropriate daily dose (5mg daily) for psoriasis without baseline blood tests…

general practicepharmacydiagnosticmedicationmethotrexate
VIChome2018-06-06

Finding into death of Rohan Grindrod

41y · Male·Sudden unexpected death in epilepsy (SUDEP)

… 16-17 November 2011. He had a Personal Emergency Response (VitalCall) device that had previously saved his life approximately 30 times. When relocating from King Street to Adrian Drive, the VitalCall device was physical…

neurologyoccupational therapysystemcommunicationcarbamazepine
NSWcommunity2022-09-16

Inquest into the disappearance of CD

36y · Male·Cannot be determined

CD, aged 36, disappeared on 17 June 2019 after exhibiting significant mental health deterioration, recent suicidal ideation, paranoia, alcohol abuse, and relationship breakdown. The coroner found sufficient evidence that…

psychiatryemergency medicinesystemcommunicationalcohol
SAhospital2012-09-05

Coroner's Finding: KAY Damian

38y · Male·Multiple injuries

…to his discharge without appropriate mental health follow-up or detention, resulting in preventable loss of life within hours.

emergency medicinepsychiatrydiagnosticcommunicationvenlafaxine
WAcommunity2008-02-25

Inquest into the Death of Kimberley Coronial Report

Multiple causes across 22 deaths: ligature compression of the neck (17 hangings)…

This coronial inquiry examined 22 deaths of Aboriginal people in the Kimberley region of Western Australia between 2000 and 2007. Seventeen were self-harm deaths, with four additional accidental deaths and one homicide. …

public healthpsychiatrysystemdelayalcohol
NSWcommunity2024-02-19

Inquest into the death of Omar Mohammad

33y · Male·Irreversible hypoxic brain injury secondary to acute cocaine toxicity

Omar Mohammad, a 33-year-old man with recent mental health concerns and drug use, ingested a small plastic bag containing cocaine whilst being arrested for trespass on 10 August 2020. He died 44 days later from irreversi…

emergency medicinetoxicologycommunicationdelaycocaine
WAhospital2021-11-29

Inquest into the Death of Miss T (Name Subject to Suppression Order)

16y · Female·acute abdominal obstruction secondary to adhesions associated with severe pelvic…

…reported; (3) discharge of a 16-year-old without ensuring responsible adult supervision or involvement of support services; (4) pressure from the 'four-hour rule' (WEAT) contributing to premature discharge; and (5) lack…

emergency medicinegeneral practicediagnosticsystemcannabis

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