Coronial
NSWcommunity2019-04-15

Inquest into the death of Shaun CRIGHTON-CROMB

19y · Male·Multiple injuries, smoke inhalation and carbon monoxide toxicity

…s, the deceased's lack of driving experience and valid licence, unfamiliarity with the vehicle, likely distraction from phone conversation, and psychological fear state from believing he was being pursued. Post-collision…

VICcommunity2017-07-11

Finding into death of Garry Montgomery Theobold

50y · Male·Multiple injuries

Garry Montgomery Theobold, aged 50, died from multiple injuries sustained in a motor vehicle collision on a wet, winding regional road with poor skid resistance. The collision involved his Toyota Prado and an unladen Mac…

forensic medicinedelay
VIChospital2015-02-16

Finding into death of Dianne Willma MacIntyre

18y · Female·Injuries sustained in motor vehicle collision (passenger)

An 18-year-old female died from injuries sustained as a passenger in a motor vehicle collision on a poorly maintained road. The vehicle struck a pothole in a wet road surface, causing loss of control and collision with o…

emergency medicinetrauma surgerysystem
VICcommunity2026-04-09

Finding into death of Bikram Dangol

30y · Male·Head and neck injury in a motorcycle incident

…ed lines without adequate abrasive material) that eliminated macro and micro texture, resulted in loss of traction when the motorcycle crossed the painted line. The coroner identified significant system failures: a water…

forensic medicinesystemcommunication
NSWPodcast2019-05-10

Inquest into the deaths of Stephanie Jane KING, Ella-Jane KABEALO and Jacob Matthew KABEALO

Female·Drowning

…anie Jane King and her two children, Ella-Jane (aged 11) and Jacob (aged 7), died when their vehicle lost traction on Dulguigan Road, North Tumbulgum, NSW, after flooding from Ex-Tropical Cyclone Debbie. The road was cov…

systemdelay
TAS2023-06-26

Coroner's Finding: Riley, Judith and Donald

75y · Female·Mrs Riley: cervical spinal injuries sustained in motor vehicle collision; Mr Ril…

This coronial finding concerns a fatal motor vehicle collision on 20 August 2021 involving two vehicles on the West Tamar Highway in Tasmania. An L2 learner driver (Ms Wright, with approximately 80 hours driving experien…

NT2019-08-09

Inquest into the death of Robin Riley, Thomas Turpin, Fabian Andrews, Cassandra Martin

Blunt force trauma from motor vehicle accident (four deceased: head injuries in …

…sengers (Thomas Turpin, 39; Cassandra Martin, 32; Fabian Andrews, 45) were killed when their vehicle lost traction on a right-hand curve. Contributing factors included: driver intoxication (0.27-0.29% BAC), excessive spe…

emergency medicineretrieval medicinesystemdelayalcohol
NSWhospital2011-11-11

Coroner's Finding: John Reginald Beech

64y · Male·Postoperative intra-abdominal bleeding from pancreatic artery injury and its con…

John Reginald Beech, 64, died at Sydney Adventist Hospital on 24 April 2007 from postoperative intra-abdominal hemorrhage following colonic surgery. One week earlier, he underwent high anterior resection and hernia repai…

anaesthesiacolorectal surgerydiagnosticdelaymorphine
WAcommunity

Inquest into the Death of Keannita SAMSON

13y · Female·Chest and Head Injuries sustained in motor vehicle crash

A 13-year-old Aboriginal girl was a passenger in a stolen vehicle that was pursued by Western Australian police. The vehicle driver, also aged 13 and inexperienced, lost control during the pursuit, causing the vehicle to…

system
VIC2014-10-02

Finding into death of David Robert Judge McVea

63y · Male·Multiple injuries (motor vehicle impact—passenger)

…ldstream, Victoria on 21 February 2007. A Toyota utility driven by Jason Lowe, with worn rear tyres, lost traction on a wet road surface with dangerously low friction properties and collided head-on with the Peugeot driv…

systemdelay
QLDhospital2013-05-22

Thoresen, Cynthia

88y · Female·pulmonary thromboembolism due to fractured right femur due to a fall

Cynthia Thoresen, 88-year-old woman with dementia and osteoporosis, fell at home and sustained a fractured femur approximately three weeks before admission. Her daughter, the registered carer, failed to seek medical atte…

orthopaedic surgeryemergency medicinedelaysystemmorphine
VICcommunity2011-03-30

Finding into death of Justin Ross Pomery

20y · Male·Massive head injuries from motor vehicle accident (bus rollover)

…se was poor road surface conditions (severe bleeding, polishing, rutting, and water pooling) that reduced traction and likely caused aquaplaning. VicRoads had identified this section as needing waterblasting since 2007 b…

systemdelay
SAcommunity2006-08-07

Coroner's Finding: ROWE Stephen and HUNT Charmaine and HUNT Olivia and FERGUSON Peter (South Road Inquest)

Unknown·Stephen Rowe: atlanto-occipital fracture dislocation (broken neck); Charmaine Hu…

…South Australia between May 2000 and March 2002. All three collisions involved southbound vehicles losing traction on a wet, slippery road surface while negotiating a sweeping right-hand bend, crossing into the path of n…

communicationsystem
WAcommunity2019-01-29

Inquest into the Death of Glenn William STRICKLAND

43y · Male·Complications of neck injury; specifically extensive brainstem infarction second…

Glenn William Strickland, an experienced Harley Davidson rider, died from brainstem infarction following severe cervical spinal injury sustained in a motorcycle crash on Julimar Road, Western Australia. He failed to nego…

emergency medicinetrauma surgerysystemdelay
WAhospital- 27 May 2014

Inquest into the Death of Julissa Teresa GILBERT

57y · Female·Intra-abdominal Haemorrhage following Appendectomy, with contributing factor of …

A 57-year-old woman with COAD, hypertension, and unrecognized severe coronary atherosclerosis presented with appendicitis. Surgery was performed by an unsupervised surgeon operating on friable tissues with limited visibi…

anaesthesiasurgerydiagnosticcommunicationaramine
VIC2011-03-30

Finding into death of Sabrina Michelle Brady

19y · Female·Mechanical asphyxia due to crush injuries sustained under coach rollover; pregna…

On 16 April 2009, a V-Line coach rolled over on the Princes Highway near Heathmere, Victoria, killing three occupants: Sabrina Brady (19 years, 7 months pregnant), her daughter Madison Dobie, and Justin Pomery. The coach…

systemdelay
VIChospital2025-05-13

Finding into death of Baby W

0y · Male·subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour

Baby W died within 40 minutes of birth from subgaleal haematoma and subarachnoid haemorrhage following a failed instrumental delivery for prolonged labour. The coroner identified critical missed opportunities in decision…

obstetricsneonatologydiagnosticproceduralclindamycin

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