Coronial
VIC2018-12

Finding into death of Bede Levi Davies

29y · Male·Acute bronchopneumonia in a man with cardiomegaly

… cardiomegaly and class III obesity. He was found unresponsive in his cell and could not be revived despite CPR. Post-mortem examination revealed significant cardiac enlargement of unknown aetiology, possibly related to…

forensic medicinecardiology
WAcommunity2023-02-28

Inquest into the Death of Paul James BRADY

35y · Male·multiple injuries

…he jumped within approximately four minutes. The officers initially failed to approach Mr Brady or commence CPR, reporting they went into 'shock' or 'froze'. However, two other officers arrived shortly after and began r…

emergency medicineforensic medicineproceduraldelaytemazepam
VICaged care2020-04-22

Finding into death of Dorothy May Nelson

81y · Female·Complications of choking on a food bolus in a woman with dementia

…ng lunch. Staff provided back thrusts but failed to recognise cardiorespiratory arrest and did not commence CPR. There was a 5-10 minute delay before recognising the severity, with conflicting staff accounts suggesting …

geriatric medicinepsychiatrydiagnosticproceduralmorphine
VICcommunity2011-08-17

Finding into death of Rickard David Thomas

29y · Male·Hypoxia as a result of cardiac arrest (ventricular fibrillation) from unknown ca…

… outdated first aid training (last certified 2000), no working portable phone at the collapse location, and CPR was not commenced during the critical 12-minute delay before paramedics arrived. Paramedic and hospital car…

intensive careparamedicineproceduralsystem
VICaged care2022-12-09

Finding into death of Blake Edwards

33y · Male·Ventricular arrhythmia associated with cardiomegaly

…ve approximately 30 minutes after being given yoghurt with his medications and could not be revived despite CPR. Autopsy confirmed cardiomegaly with left ventricular dilatation as the underlying cause. His pacemaker was…

cardiologypathologyoxycodone
WAhospital2025-07-22

Inquest into the Death of Samaan Salah Tilmiz ELSAMIN

21y · Male·unascertained

…tient respirations during seclusion observation, unclear allocation of nursing responsibility, inconsistent CPR assessment protocols, and incomplete resuscitation documentation. The primary barrier to optimal care was a…

psychiatryintensive caresystemdelayclozapine
TAS2021-11-01

Coroner's Finding: Lane, Christopher Mark

Male·ruptured spleen

… into his abdomen. He remained conscious initially but deteriorated rapidly. Bystanders initiated competent CPR within minutes of his collapse, and emergency services responded as quickly as feasible from a remote locat…

emergency medicinetrauma surgery
TAScommunity2017-02-20

Coroner's Finding: Scheffer, Yolande

49y · Female·drowning

…and nose. Her daughter kept her head above water until surf lifeguards arrived within minutes and commenced CPR. Despite resuscitation efforts continuing at hospital, she could not be revived. The coroner found this was…

emergency medicinepathology
NSWhospital2019-12-20

Inquest into the death of Blair DALTON

35y · Female·hypoxic brain injury, with strangulation being an antecedent cause

… of warning signs in domestic relationships (prior police contact, documented tension), importance of early CPR initiation by bystanders and first responders, and appropriate ICU management of hypoxic-ischaemic brain in…

emergency medicineintensive care
QLD2013-03-28

Lambert, Stuart John

31y · Male·Chest injuries (principal cause) with autism and epilepsy as underlying causes

…mpts. Key clinical lessons include: respite carers require appropriate training in emergency management and CPR; carers working with epilepsy patients need current first aid certification; overnight placements at unsuit…

general practiceemergency medicinecommunicationsystemepilim ec
SA2019-05-09

Coroner's Finding: PIKE Lucas Adam

43y · Male·morphine (heroin) toxicity

…an Dr K.'s daughter (also present), likely entering cardiac arrest shortly after injection. Dr K. initiated CPR upon discovering the collapsed patients but Pike could not be resuscitated. The coroner found no criticism …

general practiceemergency medicineheroin
QLD2007-02-23

James, Joseph Edwin

67y · Male·Coronary atherosclerosis and emphysema

…ood health according to routine prison medical assessments. He was found unconscious in his cell shower and CPR was initiated immediately by nursing and correctional staff. The coroner found that correctional services a…

emergency medicinecardiology
TAScommunity2024-06-13

Coroner's Finding: Pearce, Leigh

43y · Male·Multiple chest injuries (including rib fractures and haemopneumothorax)

…hin strap, and he fell approximately two metres, landing on his chest and head. Despite immediate bystander CPR and paramedic resuscitation efforts, he could not be revived. This death resulted entirely from the decease…

VICcommunity2023-12-08

Finding into death of Ricky James Broughton

47y · Male·Complications of acute agitation in the setting of a prolonged struggle in an ac…

…sment Order on 3 May 2018, police pursued and restrained him. During restraint, he rapidly deteriorated but CPR was not commenced until 9 minutes after becoming unconscious. He died from complications of acute agitation…

psychiatrygeneral practicecommunicationsystemquetiapine
WApolice custody_and_home

Inquest into the Death of Desmond Richard KICKETT

34y · Male·multiple organ failure following cardiorespiratory arrest in a man with focal co…

…propriately used minimal restraint, placed him in recovery position, monitored him regularly, and initiated CPR when his condition deteriorated. The coroner found no police culpability. Clinical lessons include: recogni…

emergency medicinecardiologymethamphetamine
VICaged care2024-05-27

Finding into death of Jon Lewis

57y · Male·Ischaemic heart disease in a man with chronic schizophrenia

…orted chest symptoms (dyspnoea, palpitations) to staff who promptly called emergency services and initiated CPR. Paramedics arrived within minutes and continued resuscitation attempts without success. The coroner found …

cardiologypsychiatryvenlafaxine
VIChome2012-07-05

Finding into death of Angela Jade Bannister

1y · Female·Chest injuries

…injuries other than the initial head injury and alleged bite were observed by her mother. Simmons performed CPR from approximately 5:30-6:20 am. Medical evidence indicated these injuries were inflicted prior to CPR and …

emergency medicinepaediatricscommunicationibuprofen
VIChome2013-06-28

Finding into death of Walter Leonard Colyer

63y · Male·Ischaemic heart disease and aortic stenosis

…osis. Sudden cardiac death in individuals with this constellation of findings is well-recognised. Bystander CPR and paramedic resuscitation were prompt but unsuccessful. The coroner found no medical management issues an…

cardiologygeneral practice
VIC2011-04-03

Finding into death of Gary Witcombe

60y · Male·Neck injury, specifically fracture of the odontoid peg of the second cervical ve…

…y party. The injury caused immediate loss of consciousness and respiratory arrest. Despite prompt bystander CPR and paramedic resuscitation, he could not be revived. The coroner found insufficient evidence to determine …

emergency medicineparamedicinealcohol
NSWaged care2021-06-23

Inquest into the death of David Grahame Jones

88y · Male·General frailty and inanition; antecedent conditions: chronic cardiac and renal …

…and treatment from Justice Health and was appropriately accommodated by Corrective Services NSW. A 'Not for CPR' order was properly in place and respected. The death was natural and occurred in the context of multiple s…

geriatric medicinepalliative care

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