Coronial

450 results for emergency procedures training

QLDcommunity2022-01-11

Noombah

39y · Male·Cardiac arrest in a person with pre-existing severe ischaemic heart disease who …

…ons man with severe ischaemic heart disease died following police restraint and ambulance care during an emergency examination authority detention. He had sniffed petrol and threatened self-harm; police located him and …

emergency medicineparamedicinediagnosticcommunicationpetrol
QLDhospital2017-09-20

Mrs R-W - Non-inquest findings

83y · Female·Hyponatraemic encephalopathy due to adverse effects of citaprolam and duloxetine…

…n of the chronic hyponatraemia, more frequent sodium retesting, and stricter documentation of escalation procedures could potentially have altered outcomes.

general medicineemergency medicinediagnosticmedicationcitalopram
QLDhome2022-07-12

Jack - Non-inquest findings

41y · Male·Stab wound to the chest

Jack, a 41-year-old man with extensive history of domestic violence perpetration across multiple relationships, died from a stab wound to the chest inflicted by his partner Sally during a domestic disturbance. Sally had …

forensic medicinecorrectional healthcommunicationsystemmethamphetamine
VIChospital2013-09-10

Finding into death of Paul Gary Larman

28y · Male·Overdose of Clozapine

A 28-year-old man with schizophrenia and substance abuse history died from clozapine overdose. Key clinical failures included: inadequate assessment of suicide risk when prescribing one month's supply to a patient presen…

psychiatryemergency medicinediagnosticmedicationclozapine
ACTPodcast2025-06-13

Inquiry Into The Orroral Valley Fire

On 27 January 2020, an ADF MRH-90 Taipan helicopter ignited a fire in Namadgi National Park, ACT, during Defence Assistance to the Civil Community operations. The crew made an unplanned landing in the high-danger Orroral…

communicationsystem
QLDhome2012-11-14

Galeano, Antonio Carmelo

39y · Male·Excited delirium, probably caused by amphetamine toxicity-induced psychosis. Dea…

…r activations. He had acute amphetamine toxicity and was displaying excited delirium—a high-risk medical emergency. Clinical lessons include: (1) excited delirium with amphetamine toxicity is potentially lethal and requ…

emergency medicinepsychiatryproceduralcommunicationamphetamine
WA2017-03-07

Inquest into the Death of Barry Matt STUART

49y · Male·ligature compression of the neck (hanging)

Barry Matt Stuart, a 49-year-old prisoner at Hakea Prison, died by suicide via ligature compression of the neck in November 2013. Critical clinical lessons include: (1) maintaining psychiatric continuity of care is essen…

psychiatrygeneral practicemedicationsystemolanzapine
VICcommunity2002-02-08

BEVERIDGE Graham

52y · Male·multiple injuries including right ventricular rupture

A 52-year-old volunteer race marshal was fatally struck by a detached Formula One race car wheel that passed through a gap in the debris fence at the 2001 Australian Grand Prix at Albert Park. The wheel was travelling at…

emergency medicineintensive caresystemdelay
VICpsychiatric hospital ward2013-03-13

Finding into death of Justin John Fraser

35y · Male·Sudden death during restraint in an agitated obese man with coronary artery athe…

Justin Fraser, a 35-year-old man with first-episode psychosis admitted to Frankston Hospital psychiatric unit, was found attempting suicide by hanging and subsequently became agitated. Security and AMT staff physically r…

psychiatryemergency medicinecommunicationsystemolanzapine
WAcommunity2019-09-23

Inquest into the Death of Sean MORGAN-SMITH

45y · Male·Abdominal injuries from being struck by reversing front-end loader

Sean Morgan-Smith, a 45-year-old Australia Post delivery worker, was struck by a reversing front-end loader while delivering mail on a residential footpath in Huntingdale, Western Australia on 24 June 2015. He sustained …

emergency medicinetrauma surgerysystemdelay
SAcommunity2009-03-06

Coroner's Finding: BRADFORD Steven Michael

20y · Male·severe blunt head trauma

Steven Bradford, a 20-year-old motorcyclist with a learner's permit, was riding an unregistered Honda CVR 600cc motorcycle illegally at high speed. After speeding on the Lincoln Highway, he was pursued by solo police off…

proceduralsystem
NSW2024-10-23

Inquest into the death of Alen Imbrisak

47y · Male·Sudden cardiac death in association with COVID-19 infection

Alen Imbrisak, a 47-year-old man incarcerated at Junee Correctional Centre, died on 26 January 2022 from sudden cardiac death in association with COVID-19 infection. He tested positive on 25 January 2022 during a centre-…

respiratory medicineemergency medicinecommunicationsystemmethadone
VICmental health2021-05-28

Finding into death of Christopher John Peter Dewhurst

27y · Male·Multiple injuries sustained after being struck by a train

Christopher Dewhurst, 27, died by suicide after being struck by a train while on ground leave from a psychiatric unit. He was a compulsory patient subject to a Temporary Treatment Order, admitted with suicidal ideation a…

psychiatryemergency medicinecommunicationsystemdesvenlafaxine
NSW2016-11-04

Inquest into the death of Phillip Hughes

25y · Male·traumatic basal subarachnoid haemorrhage due to vertebral artery dissection

…ield Shield match. The injury was unsurvivable regardless of medical response. However, systemic gaps in emergency response procedures were identified: ambulance was not called for over 6 minutes, the initial 000 call l…

emergency medicineneurosurgerycommunicationsystem
TAS2022-02-24

Coroner's Finding: Scott, Paul Stephen

61y · Male·asphyxial death due to hanging

Paul Stephen Scott, aged 61, died by hanging while on leave from psychiatric inpatient care. He had been admitted to Spencer Clinic on 11 January 2018 with suicidal ideation and complex psychiatric presentation. Despite …

psychiatrygeneral practicesystemcommunicationvenlafaxine
NSWhome2024-12-04

Inquest into the death of HB

1y · Female·Multiple injuries (subdural clot, multiple rib fractures, injuries to liver, blo…

A 20-month-old girl died from fatal injuries inflicted by her mother's partner. She presented to hospital twice in two weeks with suspicious injuries: facial injuries on 7 June attributed to a puppy, and more extensive f…

paediatricsemergency medicinesystemcommunication
SA2010-11-19

Coroner's Finding: PARKER Laura

40y · Female·hypoxic encephalopathy and epilepsy with diffuse fibrillary astrocytoma within t…

… avoiding detention despite manifestations of acute psychiatric illness; (3) delayed response to medical emergency—over 10 minutes elapsed before cell entry after seizure detection; (4) failure to notify medical staff i…

neurologypsychiatrydiagnosticcommunicationvigabatrin
TASPodcast2025-06-19

Coroner's Finding: Findings in relation to Shane Navin, Leigh Mundy, Dennis Neagle and Anthony Seymour

Multiple causes: Shane Navin - drowning; Leigh Mundy and Dennis Neagle - multipl…

…tors, particularly regarding mental health and cardiac conditions; sub-optimal communication systems for emergency response; and lack of mandatory safety measures. The coroner emphasised that racing cars designed for co…

diagnosticsystemmirtazapine
QLDhospital2022-07-08

R - Non-inquest findings

0y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…

A 10-month-old boy died following elective cleft palate repair surgery complicated by post-operative respiratory distress and subsequent cardiorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pu…

anaesthesiaintensive carediagnosticproceduralpropofol
NThospital2018-09-21

Inquest into the death of David Fensom

67y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …

…pseudomonal sepsis. While subsequent ICU management was appropriate, the delayed diagnosis of a surgical emergency in a patient with known adhesion history proved fatal. Clinicians should maintain high suspicion for mes…

general surgeryemergency medicinediagnosticcommunicationfentanyl
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