Coronial
NTcommunity2024-11-15

Inquest into the death of Kumanjayi Jurrah

2y · Male·accidental drowning

A 2-year-old boy drowned at a public pool in a remote Australian community during a childcare centre excursion. Critical clinical and organisational failures contributed: no formal risk assessment was documented for the …

public healthemergency medicineproceduralsystem
VIChospital2011-12-14

Finding into death of Poppy Louise Habgood

0y · Female·Perinatal asphyxia

Poppy Louise Habgood was born at 0100 hours on 10 July 2008 by emergency caesarean section at 42 weeks gestation, weighing 3968g. She was born severely asphyxiated with a heart rate of 60bpm and died at 0126 hours despit…

obstetricsmidwiferydiagnosticcommunication
WA2025-03-10

Inquest into the Death of Ricky-Lee COUND

22y · Male·ligature compression of the neck (hanging)

Ricky-Lee Cound, 22, an Aboriginal man with FASD, died by hanging in his Hakea Prison cell on 25 March 2022. At 4.11pm, Mr Cound called requesting a monitored safe cell to prevent self-harm, demonstrating clear risk perc…

psychologygeneral medicinediagnosticcommunicationaripiprazole
QLDhospital2018-09-26

Mann, Renae Jean

43y · Female·acute toxic effects of amitriptyline

A 43-year-old woman with depression was admitted to Gold Coast University Hospital with suspected amitriptyline overdose. After 11 hours of ED monitoring, she was medically cleared and transferred to a mental health asse…

emergency medicinepsychiatrydiagnosticcommunicationamitriptyline
QLD2005-10-07

Creegan, Thomas

47y · Male·Myocardial ischaemia as a result of undiagnosed coronary artery disease; cerebra…

Thomas Creegan, a 47-year-old UK tourist, died during a second introductory resort dive at the Great Barrier Reef after becoming separated from his instructor and ascending rapidly to the surface. He lost consciousness s…

diving medicineemergency medicinecommunicationprocedural
SAcommunity2013-04-18

Coroner's Finding: JOHNSON Olivia Jean

0y · Female·dehydration

…location when making discharge decisions. Olivia deteriorated rapidly at home and died that evening despite CPR by her parents. The coroner found her death was preventable—admission to hospital would likely have enabled…

general practicepaediatricsdiagnosticcommunicationgastrolyte
QLDhome2012-11-14

Galeano, Antonio Carmelo

39y · Male·Excited delirium, probably caused by amphetamine toxicity-induced psychosis. Dea…

Antonio Carmelo Galeano died in police custody on 12 June 2009 after a protracted struggle and multiple taser activations. He had acute amphetamine toxicity and was displaying excited delirium—a high-risk medical emergen…

emergency medicinepsychiatryproceduralcommunicationamphetamine
TAS2017-06-30

Coroner's Finding: Monson, Troy Colin; Michael, Robin and Mitchell, Scott Clifford

Unknown·Troy Monson: asphyxia due to partially suspended hanging using seatbelt; Robin M…

This inquest examined three deaths in Tasmanian custody: Troy Monson (asphyxiation in prison van during transport in June 2015), Robin Michael (hanging in prison cell June 2015), and Scott Mitchell (cardiac arrhythmia fr…

psychiatrypsychologydiagnosticsystemolanzapine
QLD2006-09-27

Mulrunji

36y · Male·intra-abdominal haemorrhage due to rupture of liver and portal vein

…equent, thorough cell checks are essential for intoxicated persons; no prisoner should be left unmonitored; CPR-trained staff and resuscitation equipment are mandatory; communication failures with Indigenous witnesses c…

forensic medicineemergency medicinediagnosticprocedural
QLDhospital2023-06-30

Booth, Yvette and Sandy, Adele and George, Shakaya (“RHD Doomadgee Cluster”)

Female·Betty: cardiac arrhythmia complicating heart failure due to consequences of past…

This inquest examined three deaths of young Aboriginal women from Doomadgee (ages 18, 37, and 17) from rheumatic heart disease (RHD) complications between September 2019 and September 2020. All three deaths were preventa…

cardiologyemergency medicinecommunicationsystempenicillin

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