Coronial
QLDhospital2018-07-30

Matthew Douglas McLachlan - Non-inquest findings

28y · Male·Mixed drug toxicity (synergistic effects of diazepam, oxycodone, and fentanyl ca…

…inated pain management across settings is essential for opioid-dependent patients; consider home-based IV therapy to reduce unsupervised hospital absences.

infectious diseasesemergency medicinecommunicationsystemfentanyl
NSWhome2025-12-17

Inquest into the death of MQ

55y · Female·acute necrotising bronchopneumonia

…pital admission; though not certainly preventable, admission would have enabled IV antibiotics and oxygen therapy that might have materially altered disease progression.

general practiceemergency medicinediagnosticdelay
NThospital2010-04-16

Inquest into the death of Dailyna Byrnes

13y · Female·cardiac arrest resulting from dehydration

A 13-month-old girl with short bowel syndrome died from cardiac arrest due to severe dehydration. She had been deteriorating with diarrhoea and vomiting on 18 February 2009, prompting nursing staff to escalate concerns t…

paediatricsemergency medicinediagnosticcommunicationoral rehydration solution
WAhospital2005-09

Inquest into the Death of Maria Donatelli

72y · Female·Peritonitis due to perforated diverticulum in transverse colon

Maria Donatelli, a 72-year-old woman with cardiac and renal disease, presented to Peel Health Campus with abdominal pain and vomiting. She was initially managed conservatively with a provisional diagnosis of pancreatitis…

general surgeryemergency medicinediagnosticcommunicationtramadol
VIChospital2012-02-22

Finding into death of Ellen Mary OConnor

90y · Female·Renal failure secondary to gentamicin therapy for urinary tract infection (sepsi…

Ellen O'Connor, a 90-year-old woman with renal artery stenosis and coronary artery disease, died from acute renal failure following gentamicin administration for Pseudomonas aeruginosa urinary tract infection. A single 2…

orthopaedic surgeryplastic and reconstructive surgerymedicationdiagnosticgentamicin
SAhospital2013-08-15

Coroner's Finding: STOCK Anthony Douglas

64y · Male·hypoxic-ischaemic encephalopathy complicating cardiac arrest due to retroperiton…

… medical assessment at 4pm would likely have identified shock, triggered investigations and supportive IV therapy, potentially preventing arrest. Key lessons: monitor anticoagulation with regular bloods; respond urgentl…

orthopaedic surgeryemergency medicinediagnosticcommunicationenoxaparin
NT2024-06-12

Inquest into the death of Mr Dooley

37y · Male·Complications due to atherosclerotic heart disease and dyslipidaemia

Glen Dooley, a 37-year-old Aboriginal man, died of atherosclerotic heart disease and dyslipidaemia while in custody at Darwin Correctional Centre. His death was avoidable. He had abnormal ECGs in 2019 and 2022 that were …

cardiologygeneral practicediagnosticcommunicationatorvastatin
WA2013-03-08

Inquest into the Death of Thoms, Gemma Geraldine

17y · Female·Acute Methylenedioxymethylamphetamine (MDMA) toxicity

Gemma Thoms, a 17-year-old girl, died from acute MDMA toxicity after consuming three ecstasy tablets at the Big Day Out music festival on 1 February 2009. She collapsed and died on 2 February 2009. Key clinical lessons: …

emergency medicineintensive carediagnosticsystemMDMA
VIChospital2026-02-05

Finding into death of Max Peter McKenzie

15y · Male·Cardiorespiratory arrest of unknown aetiology complicating hypoxic ischaemic enc…

Max McKenzie, a 15-year-old with asthma and food allergies, died from cardiorespiratory arrest complicating hypoxic ischaemic encephalopathy after severe refractory anaphylaxis. After eating apple crumble containing nuts…

emergency medicineparamedicinedelaycommunicationadrenaline

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