Coronial
SAhospital2006-09-25

Coroner's Finding: McCARTHY Elly Sarahnia

13y · Female·cerebral oedema and infarction secondary to extensive subdural empyema

…anged urgent transfer to Women's and Children's Hospital for neurosurgery. The coroner found Elly's Glasgow Coma Score was 13-15 when she left Flinders, with a normal clinical trajectory. However, she suffered catastroph…

paediatricsemergency medicinediagnosticcommunicationtrimethoprim
TAScommunity2022-08-24

Coroner's Finding: ZM De-identified

14y · Male·chest and abdominal injuries following a single motorcycle collision

A 14-year-old male died from chest and abdominal injuries sustained in a motorcycle collision on Christmas Day 2020. He was riding an unregistered Yamaha WR 450F at approximately 96 km/h (nearly double the 50 km/h speed …

trauma surgeryemergency medicinealcohol
NT2010-04-22

Inquest into the death of Zephaniah Namundja

22y · Male·Blunt head injury occasioned when the deceased fell from a moving vehicle

…ulvert at high speed without headlights. Critical clinical lessons include: severe head injury with Glasgow Coma Score 3 requires immediate specialist neurosurgical assessment; early communication about apparent neurolog…

alcohol
VICaged care2011-09-05

Finding into death of Neil Charles Bethune

83y · Male·Ischaemic heart disease secondary to coronary atherosclerosis

…s and antipsychotics. During transfer between facilities, he experienced altered consciousness with Glasgow Coma Score dropping to 3, requiring diversion to hospital for investigation. Despite normal investigations, he w…

psychiatrygeriatric medicineoxazepam
QLDhospital2015-07-28

Mills, Stephen John

57y · Male·Head injury from fall; with coronary atherosclerosis and complete heart block wi…

A 57-year-old man with bipolar disorder died from head injury following a fall at Toowong Private Hospital. Critical failures in falls risk management were identified: no formal falls risk assessment was completed on adm…

psychiatryneurosurgerysystemcommunicationseroquel xr
WAhospital2020-11-20

Inquest into the Death of Trent Nathaniel ROBERTSON

44y · Male·head and neck injuries with terminal palliative care

Trent Robertson, 44, died from severe head and neck injuries sustained in a high-speed motorcycle crash on 27 May 2018 after evading a brief police traffic stop. Police observed him speeding at 92 km/h in a 60 km/h zone,…

trauma surgeryintensive care
VIChospital2018-11-09

Finding into death of MDJ

34y · Male·Hypoxic/ischaemic encephalopathy; Heroin toxicity

…lowing heroin toxicity after injecting in a public park. He presented to hospital unresponsive with Glasgow Coma Score 3 and multiorgan failure, showing signs of brain death within hours. He was extubated after family co…

intensive careemergency medicineheroin
NSW2014-04-02

Inquest into the death of Reece POTTER

23y · Male·blunt force head injuries sustained when thrown from his horse during a race

A 23-year-old jockey, Reece Potter, died from severe head injuries sustained when thrown from his horse during a race at Tottenham Picnic Races on 12 March 2011. The horse 'Half Handy' suffered a spontaneous fractured pe…

systemdelay
VIChospital2024-09-22

Finding into death of Carl Edward Medlyn

51y · Male·Aspiration pneumonia secondary to traumatic brain injury arising from a scooter …

A 51-year-old man suffered a severe traumatic brain injury in an electric scooter crash on 14 March 2022 and died from aspiration pneumonia on 4 August 2022. He was riding a high-powered scooter (capable of 85km/h) at ex…

neurosurgerytrauma surgerycannabis
VIC2025-10-29

Finding into death of David James Klingberg

55y · Male·Complications of traumatic head injury sustained in a workplace incident (pallia…

David Klingberg, a 55-year-old experienced pile testing engineer, died from traumatic head injury sustained when an auxiliary line hook on a piling rig struck him in the face at a construction site. The hook became jamme…

emergency medicineintensive caresystemmorphine
VIChospital2014-09-11

Finding into death of Daniel Raymond Cowan

15y · Male·global hypoxic cerebral injury following medical intervention for high velocity …

… Children's Hospital including neurosurgery, the injury was devastating. He initially survived with Glasgow Coma Scale 9, underwent intubation, surgery, and decompressive craniectomy. However, he developed staphylococcal…

neurosurgeryintensive caremidazolam
QLDhospital2017-10-06

Parsons, Ann

59y · Female·Global cerebral oedema due to hypoxic cerebral ischaemia following cardiac arres…

59-year-old woman admitted with newly diagnosed grade 4 glioblastoma underwent surgery 16 days later after delays during consultant's planned leave. Post-operative complications included ischaemic stroke confirmed on ima…

neurosurgeryintensive carediagnosticcommunicationdexamethasone
SAhospital2009-03-18

Coroner's Finding: COX Ricky Glen

17y · Male·refractory status epilepticus caused by either a viral infection, an underlying …

…ated rapidly with seizures and was transferred to hospital. Despite trials of 8 anticonvulsants and induced coma, his seizures persisted, causing brain swelling, coning, and brain death. No clinical mismanagement was ide…

neurologyemergency medicinesystemcommunicationdicloxacillin
VICmental health2023-05-22

Finding into death of Jennifer Gebert

49y · Female·Unascertained; most likely cardiac abnormality

…RC zero-tolerance alcohol policy, was assessed and medically cleared after 7.5 hours with improving Glasgow Coma Scale (13→15) and normal vital signs, then transferred to the SAAPU where she was found unresponsive at 1am…

psychiatryemergency medicinealcohol
VICcommunity2013-09-04

Finding into death of Cassilla Ellen Dooley

34y · Female·Mixed drug toxicity (ethanol, methadone, diazepam and risperidone)

…ther than escalate was within reasonable care standards given Cassie could walk, communicate, and showed no coma signs. The coroner found no clinical management failures. Key lessons include: establishing clear, document…

psychiatryemergency medicinecommunicationsystemalcohol
VIChome2025-08-07

Finding into death of Emma Louise Terrill

41y · Female·Aspiration pneumonia in the setting of a mixed drug toxicity

Emma Terrill, 41, died from aspiration pneumonia in the setting of mixed drug toxicity. Post-mortem toxicology revealed elevated tramadol with benzodiazepines (alprazolam, diazepam, temazepam, oxazepam) causing synergist…

general practicepsychiatrysystemtramadol
NSWhome2016-09-30

Inquest into the death of Terry Riordan

45y · Male·multi-drug toxicity from ingestion of methadone and amitriptyline

Terry Riordan, 45, died from multi-drug toxicity caused by ingesting amitriptyline and methadone in April 2015. He had complex medical and psychiatric comorbidities, substance abuse issues, and was under care of his GP D…

general practicepsychiatrymedicationdiagnosticmethadone
NSWhospital2020-09-25

Inquest into the death of Gregory MASTERS

52y · Male·Polypharmacy overdose of amitriptyline and doxylamine in the context of underlyi…

A 52-year-old man with chronic facial pain, depression, obesity, cardiovascular disease and obstructive sleep apnoea died following restraint in ICU. He had ingested a polypharmacy overdose of amitriptyline and doxylamin…

intensive carepsychiatryamitriptyline
VIChospital2021-12-06

Finding into death of Ingeburg Hildegard Muller

85y · Female·Staphylococcus bacteremia complicating multiple injuries sustained in a motor ve…

… spine fractures) in a motor vehicle collision on 20 June 2018. She was treated with ICU admission, induced coma, and three surgical fixations. Initial recovery appeared successful, but she developed a wound infection po…

emergency medicineintensive caresystemantibiotics
NThospital2005-04-06

Inquest into the death of Peter Wiryal

48y · Male·Cerebrovascular Accident (stroke) caused by subdural haemorrhage, which resulted…

…as discharged from Royal Darwin Hospital on 4 April after initial assessment showed minor injuries (Glasgow Coma Score 13→15). However, he deteriorated over the following days and was admitted to Danila Dilba on 8 April …

emergency medicineneurosurgerydiagnosticcommunicationalcohol

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