Coronial

45 results for essential hypertension

VIChospital2025-09-30

Finding into death of Robert Thoai Dao

73y · Male·Complications of cervical fractures and spinal injury (operated), sustained in a…

A 73-year-old man with multiple comorbidities (diabetes, cardiac disease, liver cancer) slipped on wet tiles outside McDonald's and sustained cervical and thoracic spine fractures with spinal cord injury. Attending param…

paramedicineemergency medicinediagnosticprocedural
QLDhospital2017-10-23

Non Inquest Findings TO

73y · Male·Sepsis (gram-negative septic shock) secondary to complications of selective inte…

…. Key clinical lesson: when SIRT is performed in post-Whipple patients, prophylactic antibiotic cover is essential to prevent biliary sepsis from gram-negative bacteria colonising the altered biliary tree.

radiologyemergency medicinediagnosticmedication
VIChospital2025-05-21

Finding into death of Nazlou (Helen) Danilidis

94y · Female·Complications of a fractured neck of femur sustained in an unwitnessed in-hospit…

…ies beyond electronic surveillance alone; adequate documentation of rounding and toileting assistance is essential; delirium assessment and cognitive impairment screening should guide fall risk interventions; minimising…

geriatric medicinecardiologysystemcommunicationlorazepam
VIChospital2023-02-28

Finding into death of Mrs K

81y · Female·Cardiac tamponade secondary to dissection of ascending aorta

An 81-year-old woman with hypertension and hypercholesterolaemia presented to the ED with sudden-onset central chest pain radiating to the jaw…

emergency medicinecardiologydiagnosticdelayaspirin
VIChome2020-08-24

Finding into death of Wayne Laurence Marshall

54y · Male·Methadone use in a man with asthma and sarcoidosis of the lungs

Wayne Marshall, a 54-year-old registered nurse, died from respiratory depression caused by methadone use in the context of underlying asthma and pulmonary sarcoidosis. He was found gasping for air at home and could not b…

emergency medicineintensive caremethadone
VICaged care2010-09-08

Finding into death of Joan Hendrickson

78y · Female·Aspiration pneumonia, epistaxis, and trauma to the face

… not find the failure to refer APATT causative of death but emphasised that procedural improvements were essential to prevent similar incidents.

general practicegeriatric medicinecommunicationsystem
VIChome2015-03-18

Finding into death of Christopher John Dokos

45y · Male·Complications of heat stroke in a man with schizophrenia

…s. Coordinated care and emergency planning for environmental health crises in vulnerable populations are essential.

psychiatrygeneral practicesystemdelayclozapine
ACThospital2014-03-03

Findings Into The Death Of Sukanya Thurairajah

56y · Female·hypoxic ischaemic encephalopathy due to inadvertent oesophageal intubation and f…

…rra Hospital on 29 July 2011. She had an adverse reaction characterised by vomiting, breathlessness and hypertension. MET team intubation was performed by first-year anaesthetic registrar Dr T., who had never previously …

anaesthesiaintensive careproceduralcommunicationhydrocortisone
NSWhome2025-07-30

Inquest into the death of Hilary Gordon-Squire

65y · Male·Pneumonia, due to chronic lung disease with atherosclerotic cardiovascular disea…

…est intentional harm, thorough forensic testing of all items at the scene (including the ceramic cup) is essential; (2) mobile phone analysis may provide crucial context about intent; (3) consideration should be given t…

forensic medicinegeneral practicesystemdelaybenzodiazepines
VIChome2011-09-13

Finding into death of Rosa Sinapi

47y · Female·risperidone toxicity

…mmediate assessment. Critical learning: clear escalation pathways for urgent mental health referrals are essential; rigid geographical boundaries should not override clinical continuity or patient safety; and GP request…

psychiatrygeneral practicesystemdelayrisperidone
TAShome2026-01-22

Coroner's Finding: Kerrie Dawn Grant

72y · Female·acute on chronic renal failure due to sepsis and chronic left leg cellulitis

Kerrie Dawn Grant, a 72-year-old woman with multiple comorbidities including pulmonary hypertension, cardiac failure, COPD, and myelofibrosis, had a well-documented history of recurrent falls with prolon…

general medicinecardiologydischargecommunication
VICaged care2020-11-05

Finding into death of Sylvia Valerie Woolford

88y · Female·Complications of fractured neck of femur

…n 12 July 2018. Clinical lessons include: adequate supervision and monitoring of aggressive residents is essential in locked dementia units; early recognition of assault-related injuries and their complications in elder…

geriatric medicineorthopaedic surgerysystem
VIChospital2018-05-28

Finding into death of Kevin Patrick O'Keeffe

82y · Male·Cardiomegaly, myocardial fibrosis and ischaemic coronary artery disease in the c…

…mpt consideration of surgical referral; (4) multidisciplinary pre-procedure review of high-risk cases is essential; (5) regular audit of complications and performance indicators should be implemented.

gastroenterologysurgeryproceduralcommunicationnoradrenaline
ACThome2012-09-24

Inquest Into The Death Of Stephen Moon

21y · Male·cardiac arrest caused by acute bilateral pneumonia

…ould be risk-managed; (5) appropriate post-discharge nursing support and updated contact information are essential for high-risk patients.

anaesthesiaintensive caredelaycommunicationpropofol
WAmental health2020-08-06

Inquest into the Death of Stephen Michael KELL

35y · Male·acute vomit aspiration in a man with acute large intestine obstruction (severe m…

…tality than agranulocytosis. Key clinical lessons: gastrointestinal monitoring for clozapine patients is essential; symptoms such as vomiting or bowel changes warrant urgent assessment; and clinicians should maintain hi…

psychiatrygastroenterologysystemdelayclozapine
NSW2022-11-24

Inquest into death of William EPERE

43y · Male·Hanging

… this case, proper carrying of the 911 tool and regular scenario-based training on hanging response were essential safeguards that could save lives in future incidents. The findings highlight systemic complacency regard…

psychiatrycorrectional healthproceduralsystemescitalopram
VICaged care2023-03-22

Finding into death of Margaret Alice Cook

88y · Female·Complications of a stage 3 sacral pressure ulcer in a woman with dementia

… and coordinate specialist wound care; and early geriatric reassessment following acute deterioration is essential to guide appropriate placement.

geriatric medicinegeneral practicesystemcommunicationflucloxacillin
VICaged care2020-01-30

Finding into death of Adele Di Quinzio

86y · Female·Sepsis complicating sacral decubitus ulceration in the setting of recent surgica…

… assessment; discharge planning must match patient needs to facility capability; proper documentation is essential; and aged care facilities need robust policies and trained staff for pressure injury management.

geriatric medicineorthopaedic surgerysystemcommunicationcefalexin
WAhospital2023-11-29

Inquest into the Death of Samuel Edward ASHBY

46y · Male·Aspiration pneumonia in an obese man with a history of diabetes mellitus, obstru…

…e sleep apnoea; (4) support for patients with cognitive impairment to maintain medical devices (CPAP) is essential. Clinicians should monitor clozapine levels closely when patients change smoking habits, adhere to CRP m…

psychiatrygeneral medicinediagnosticsystemclozapine
SAhospital2015-03-06

Coroner's Finding: SIMOS Theodoras Joannas

48y · Male·undetermined

…(not RFDS/ambulance) may be preferable; careful medication choice considering respiratory sensitivity is essential; coordination between services (local hospital, psychiatric triage, retrieval services) requires defined…

psychiatrygeneral practicesystemdelayhaloperidol

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