Coronial

52 results for speech delay

VIC2018-10-16

Finding into death of Kevin Chuter

67y · Male·Ingestion of liniment (methyl salicylate) resulting in seizures and cardiac arre…

Kevin Chuter, a 67-year-old man with severe intellectual disability and no speech, died from ingestion of liniment (methyl salicylate in vegetable oil) on 8 May 2005. While in a community …

emergency medicinetoxicologycommunicationdelayliniment
SAcommunity2013-06-13

Coroner's Finding: EVANS Bernard Francis

57y · Male·multiple injuries from motor vehicle collision

…ter failing a clinic appointment on 13 January, staff noted acute psychiatric symptoms (incoherence, rapid speech) and the CTO was revoked, making him liable for detention. He was not apprehended in Victoria. He was subs…

psychiatryemergency medicinesystemdelaylithium
TAShospital2017-01-03

Coroner's Finding: Summerfeldt; Ian Patrick

48y · Male·sepsis and renal failure due to perforated gastric ulcer

…nical observations were normal and he self-discharged. He re-presented on 22 October in shock with slurred speech, mottled skin, and pale appearance, found lying outside his home. Despite worsening pain throughout the af…

emergency medicinegeneral practicediagnosticdelayketorolac
WAhospital2019-12-20

Inquest into the Death of Child TJW

7y · Female·aspiration pneumonia leading to multi-organ failure in a female child with compl…

A child with severe cerebral palsy, hypoxic ischaemic encephalopathy, microcephaly and seizure disorder died of aspiration pneumonia leading to multi-organ failure. Born with severe perinatal brain injury, she had comple…

paediatricsneurologymorphine
QLDhome2025-10-15

Inquest into the death of Tristian Jaemes Frahm

11y · Male·Brown snake envenomation

…om a ride-on mower at a rural property. He exhibited early collapse symptoms (dizziness, vomiting, slurred speech) consistent with snake venom-induced coagulopathy. Three adults, including his father, were informed of po…

emergency medicinetoxicologydiagnosticdelay
VICcommunity2025-07-17

Finding into death of John Michael Jurdeczka

62y · Male·Hypoxic ischaemic encephalopathy complicating cardiac arrest in setting of acute…

John Michael Jurdeczka, a 62-year-old man with autism, intellectual disability, and dysphagia, died from hypoxic ischaemic encephalopathy following cardiac arrest caused by acute upper airway obstruction from a food bolu…

speech pathologygeneral practicecommunicationsystemmorphine
SAhome2013-06-13

Coroner's Finding: LAMBERT Judith Ann

69y · Female·left pontine haemorrhage with re-bleeding associated with hypertensive vascular …

…eeding. On 2 February 2010, her GP referred her for a CT head scan after she reported two weeks of slurred speech. The scan on 11 February revealed a pontine mass (haemorrhage vs tumour). The radiologist Dr B. convey urg…

general practiceradiologycommunicationdelay
TASaged care2026-05-19

Coroner's Finding: de-identified BE

85y · Male·systemic sepsis due to infected right perineal ulcer and associated perianal abs…

…e progressively worsened despite preventive measures. Critical failures in clinical management included: a delayed referral to wound care specialist (referred late October, reviewed only late November—a month later), in…

geriatric medicinegeneral practicedelaymedication
VIChome2021-12-21

Finding into death of Geoffrey Alan Locks

50y · Male·Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (t…

…efore contacting his wife and then requesting ambulance at 01:05. Paramedics arrived 1:13 but faced access delays due to a concurrent police incident. Though no delay occurred once ambulance was appropriately requested,…

ENT surgeryoncologysystemcommunicationmethadone
VIChospital2012-04-05

Finding into death of Abdullah Kocoglu

4y · Male·Complications of cutaneous thermal burn injuries

Abdullah Kocoglu, age 4, died from complications of severe thermal burn injuries sustained in a house fire on 14 February 2011 at his grandparents' home in Hampton Park, Victoria. The fire was ignited when Abdullah playe…

plastic and reconstructive surgeryintensive caresystemdelay
VIChome2015-10-30

Finding into death of Christian Jay Sherwood Peck

3y · Male·consistent with drowning in a boy with autism (on historical grounds)

Christian, aged 3 years 11 months with autism spectrum disorder and a significant tendency to abscond, died by drowning in the Yarra River after escaping through an unsecured window at his father's house on 30 October 20…

paediatricsspeech pathologysystemdelaycannabis
SAhospital2008-08-15

Coroner's Finding: EDWARDS Natasha Anne

31y · Female·right cerebellar cerebrovascular accident (cerebellar infarction with obstructiv…

31-year-old woman presented with acute onset headache, dizziness, vomiting, facial numbness and speech difficulties. Initial CT brain showed equivocal left temporal hypodensity. Dr B. diagnosed acute migraine/…

neurologygeneral medicinediagnosticdelaymetoclopramide
VIChospital2023-05-24

Finding into death of Mr V

73y · Male·Combined effects of cerebrovascular accident and subsequent iatrogenic related i…

A 73-year-old man presented to ED with acute facial droop and speech difficulty on 5 September 2020. He was misdiagnosed with Bell's palsy despite clinical features suggestive…

emergency medicineneurologydiagnosticcommunicationprednisolone
TAShome2023-04-03

Coroner's Finding: De-identified HJ

71y · Female·starvation

A 71-year-old woman with chronic mental illness died of starvation in her home in Tasmania. Police attended on 9 December 2021 for a welfare check and found her severely malnourished, mentally unwell, and unable to care …

psychiatrygeneral practicecommunicationsystem
WAhospital2023-11-17

Inquest into the Death of Child MD (Name Subject to a Suppression Order)

2y · Male·multiorgan failure in a boy with clinically suspected sepsis and Cockayne syndro…

A 2-year-old boy with Cockayne syndrome (a rare life-limiting genetic condition) died from multiorgan failure due to clinically suspected sepsis following hospitalisation for acute illness with vomiting, lethargy and poo…

intensive carepaediatricsmedicationceftriaxone
NThospital2019-11-22

Inquest into the death of Lebron Douglas Martin

4y · Male·respiratory failure secondary to pneumonia on a background of Niemann Pick Type …

Lebron Martin was a 4-year-old Aboriginal child with Niemann-Pick Type C disease, a progressive neurodegenerative disorder. He died from respiratory failure secondary to pneumonia in December 2017. Four months prior to h…

paediatricsneurologysystemcommunicationamoxicillin
QLDhome2025-07-15

Inquest into the death of Daniel Thomas Wright

8y · Male·prematurity-associated lung and bowel disease

…nfant (born at 24 weeks) with multiple complex medical needs including chronic lung disease, developmental delay, and failure to thrive. He died aged eight months from prematurity-associated lung and bowel disease while…

neonatologypaediatricsdiagnosticcommunication
SAhospital2003-12-19

Coroner's Finding: HAWKE Anne Elizabeth

33y · Female·Raised intracranial pressure secondary to thrombosis of the superior sagittal, t…

A 33-year-old woman presented with acute neurological symptoms (headaches, weakness, slurred speech, seizures) on 26 August 2000. Initial CT imaging showed focal haemorrhage with oedema; repeat CT after 50 …

neurosurgeryradiologydiagnosticcommunicationoral contraceptive pill
WAprison2024-02-21

Inquest into the Death of Iain Campbell BUCHANAN

65y · Male·complications, including pneumonia, of traumatic brain injury

A 65-year-old male prisoner died from complications of severe traumatic brain injury sustained when punched by another prisoner at Hakea Prison. He fell backwards, striking his head, and was assessed at the prison medica…

neurosurgeryemergency medicinedelaysystem
NSW2019-10-25

Inquest into the death of R N

58y · Male·asphyxiation by ligature

A 58-year-old Cambodian male with basic English skills died by suicide in prison after 7 days in custody on remand for assault. Critical failures in the reception screening process included: incomplete identification and…

psychiatrycorrectional healthcommunicationsystem

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