Coronial

138 results for physical examination

VIChome2014-03-17

Finding into death of Marcus Michael Christopher Charles

0y · Male·Complications of small bowel obstruction due to post operative adhesions

…cted transport to the Royal Children's Hospital. The coroner found the history-taking unsatisfactory, the physical examination inadequate (failing to note obvious surgical scarring the mother highlighted), and the recomm…

emergency medicineparamedicinediagnosticcommunicationranitidine
VIChome2014-03-06

Finding into death of Shane Gregory Hunt

48y · Male·Head injury from blunt force trauma

Shane Gregory Hunt died from blunt force trauma to the head sustained during a physical altercation on 26 November 2008 in Werribee. Medical examination revealed multiple head injuries from a w…

forensic medicineneurosurgery
QLDhome2005

Shaw, Lillian Margaret

67y · Female·perforated gastric ulcer; morphine toxicity also made a significant contribution

…nted with vomiting and abdominal pain over 36 hours. A GP visited three times without performing adequate physical examination, failed to inspect concerning dark vomitus, and did not firmly insist on hospitalisation desp…

general practicegastroenterologydiagnosticmedicationtramadol
SAhospital2005-06-03

Coroner's Finding: SORENSEN Ruth Bengta Maria

69y · Female·faecal peritonitis due to small bowel obstruction and perforation due to periton…

…y Department with abdominal pain and vomiting. The doctor did not take adequate history, perform thorough physical examination, or order basic investigations including blood tests or abdominal X-ray. She was discharged a…

emergency medicinesurgerydiagnosticcommunicationprochlorperazine
QLDaged care2018-04-09

Enid Patricia Hiddle - Non-inquest findings

81y · Female·Acute pyelonephritis (kidney infection) in combination with severe coronary arte…

…ly documented or acted upon. The treating GP was unavailable until the day of death and did not perform a physical examination or take observations despite two-week absence. An undiagnosed kidney infection progressed to …

general practiceemergency medicinediagnosticcommunication
VICcommunity2026-04-13

Finding into death of David Evan Wild

61y · Male·Natural causes unascertained

…llowing aspiration pneumonia treatment and died unexpectedly in his sleep on 20 April 2025. Post-mortem examination was unremarkable. The coroner found no deficiency in clinical management by OnCall staff or treating cl…

geriatric medicineneurologyfluoxetine
SAhospital2007-09-18

Coroner's Finding: MARKANTONAKIS Stefanos

63y · Male·uncontrolled haemorrhage from ruptured aortic aneurysm

…y on chronic back pain. He was not fully assessed until discovered to be pale, sweaty, and pulseless on examination in the emergency department cubicle, at which point he was rushed to theatre. He died from uncontrolled…

emergency medicineparamedicinediagnosticcommunicationparacetamol/codeine
SA2021-06-02

Coroner's Finding: DUFFIELD Clinton John

35y · Male·unascertained - multifactorial cardiorespiratory arrest

…acute psychotic behaviour with paranoia, aggression, and 'super-strength' during restraint. Post-mortem examination revealed no specific cause of death. Forensic pathologist Dr H. concluded death was multifactorial, pos…

forensic medicineemergency medicinecannabis
NSWhospital2017-12-01

Inquest into the death of Carey Alexander

13y · Male·borderline myocarditis, most likely due to influenza A virus infection

A 13-year-old previously healthy boy with borderline myocarditis presented to an adult ED with flu-like symptoms, lethargy, dizziness, syncope and inability to walk unaided. Despite these concerning features, he was disc…

emergency medicinepaediatricsdiagnosticcommunicationparacetamol
NSW2020-11-03

Inquest into the death of Lawrence Hausia

30y · Male·atherosclerotic coronary artery disease

…c coronary artery disease while in custody at Metropolitan Reception and Remand Centre. He had engaged in physical activities including boxing in the exercise yard, then returned to his cell complaining of feeling hot an…

emergency medicinecardiologymetformin
VICaged care2024-03-28

Finding into death of Joseph David Jones

76y · Male·Unascertained - natural causes

…d on intramuscular olanzapine 10mg daily and reviewed by psychiatric staff on 30 November and 2 December. Physical health assessments were performed, though examination was difficult due to patient refusal and challengin…

psychiatrygeriatric medicineolanzapine
TAS2020-10-27

Coroner's Finding: Mansell, Robert Charles

42y · Male·Cause of death cannot be determined

…died elsewhere. Key clinical lesson: never accept an uncorroborated account of a death without rigorous examination of objective evidence, especially when the account contains implausibilities. Early investigation shoul…

systemdelay
WAhospital2011-11-22

Inquest into the Death of Ashdown

27y · Male·cardiac arrhythmia during restraint; mechanism involved hypoxia and asphyxiation…

…tant paranoid schizophrenia, died at Graylands Hospital on 12 October 2007 from cardiac arrhythmia during physical restraint. After assaulting another patient while psychotic, he was restrained face-down by security and …

psychiatryintensive careproceduralsystemhaloperidol
VIC2018-04-16

Finding into death of Jason Joseph Mirko Ljepojevic

30y · Male·Haemopericardium due to dissecting aortic aneurysm secondary to bicuspid aortic …

…on presented with severe central chest pain radiating to neck and back after gym exercise. A GP conducted physical examination, ECG, and diagnosed musculoskeletal pain. Pain improved within hours. He died the next day fr…

general practiceemergency medicineparacetamol
QLD2009-04-24

Broe, Stephen James

45y · Male·Fulminant cardio-pulmonary decompression sickness incidental to deep water techn…

… cardio-pulmonary decompression sickness following a technical deep dive to 50 metres. The dive medical examination conducted by Dr E. in January 2005 was inadequate—he failed to make thorough inquiries about Broe's sle…

diving medicinediagnosticcommunicationmidamor
NSWhospital2015-08-17

Inquest into the death of Manjit SINGH

33y · Male·hypoxic respiratory failure following right pneumonectomy for treatment of sever…

… India. Critical clinical lessons include: the importance of face-to-face pre-discharge TB screening with physical examination rather than telephone assessments; reviewing radiologist reports alongside clinician interpre…

respiratory medicinecardiothoracic surgerydiagnosticcommunicationtuberculosis medications
NSWhospital2019-12-13

Inquest into the death of Luca RASO

13y · Male·Peritonitis secondary to ruptured gangrenous acute appendicitis

…es included: inadequate history-taking (not documenting pain severity or functional impact), incomplete examination (cursory vital signs, no pulse recorded, no stethoscope used), failure to investigate despite deteriora…

general practiceemergency medicinediagnosticcommunication
WAhospital2017-01-20

Inquest into the Death of Tamika Patricia Carol ULLRICH

23y · Female·chronic hydrocephalus with brain swelling

…us presented to the ED with neck pain, headache and vomiting. Dr B. assessed her briefly without formal examination or detailed history, prescribed ketorolac and diazepam, and discharged her after she vomited. She died …

emergency medicinegeneral practicediagnosticcommunicationcelecoxib
VICaged care2022-11-30

Finding into death of Ian Dunlop

74y · Male·Pericarditis post aortic valve surgery with large pericardial effusion leading t…

…ther than seeking medical review. A doctor was not called despite clear protocol requirements. Clinical examination by a physician might have detected signs of heart failure and elevated jugular venous pressure, potenti…

cardiothoracic surgerycardiologycommunicationsystemapixaban
VICmental health2012-03-06

Finding into death of Nikos Karagiannis

26y · Male·Unascertained on an unequivocal medical or pathological basis; likely multifacto…

…ric unit. He was found unresponsive in bed after having no direct contact from 10pm to 9am, with only non-physical window checks during this period. Post-mortem examination revealed multiple medical conditions including …

psychiatryforensic medicinedelaysystemclozapine

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