Coronial

536 results for trauma assessment

QLDcommunity2015-08-03

Inquest into nine (9) deaths caused by Quad Bike accidents

Multiple causes across nine deaths; primary causes included rollover with crush …

This is a complex coronial inquest examining nine quad bike deaths in Queensland, with a focus on prevention through regulatory and design measures. Key clinical and safety lessons include: (1) helmet use is critical—33.…

systemdelay
WAprison2017-02-28

Inquest into the Death of Jayden Stafford BENNELL

20y · Male·ligature compression of the neck (hanging)

…re at Casuarina 'inadequate,' describing the lack of psychiatric access as a 'lost opportunity' for risk assessment, though noting that more frequent psychiatric contact may not have altered outcomes given potential medi…

psychiatrycorrectional healthcommunicationsystemquetiapine
WAcommunity2008-02-25

Inquest into the Death of Kimberley Coronial Report

Multiple causes across 22 deaths: ligature compression of the neck (17 hangings)…

This coronial inquiry examined 22 deaths of Aboriginal people in the Kimberley region of Western Australia between 2000 and 2007. Seventeen were self-harm deaths, with four additional accidental deaths and one homicide. …

public healthpsychiatrysystemdelayalcohol
NT2003-03-28

Inquest into the death of Rita Dandy

38y · Female·Multiple injuries sustained in a motor vehicle accident in which the deceased wa…

Rita Dandy, a 38-year-old Aboriginal woman with chronic alcohol use disorder, died from multiple injuries after being struck by a motor vehicle while lying on the Stuart Highway near Darwin. She had been released from pr…

forensic medicineemergency medicinesystemdelayalcohol
VIChome2026-03-20

Finding into death of HD S

41y · Female·Multiple injuries from assault

…n with physical disability and stable mental health was killed by her adult son through severe blunt force trauma including extensive rib fractures causing flail chest, pneumohaemothorax, liver lacerations, and brain inj…

communicationsystemcannabis
VICcommunity2022-12-01

Finding into death of Gabriel Messo

30y · Male·Gunshot wounds to the chest

…al health and police must be thorough and comprehensive; police s351 transfers require adequate clinical assessment; Emergency Department registrars should have access to comprehensive mental health history (CMI) before …

psychiatryemergency medicinecommunicationsystem
WAcommunity2010-12-21

Inquest into the Death of Njana

24y · Male·left intracerebral haemorrhage and consequential brain bleeding resulting from h…

Hendrick Njana, a 24-year-old Aboriginal male, was assaulted on 27 December 2008 by Shaun Steven Midd at a service station in Broome, suffering a strike to the head causing unconsciousness, kicks to the head with steel-c…

emergency medicineintensive carecommunicationdelayalcohol
SA2018-11-01

Coroner's Finding: CASTILLO-RIFFO Jorge Alberto

54y · Male·hypoxic-ischaemic encephalopathy resulting from neck compression due to entrapme…

… have used a boom lift or alternative method with proper SWMS. Key lessons: SWMS development forces risk assessment and safer alternatives; spotters essential; standardised scissor lift controls needed nationally.

occupational and environmental healthforensic medicinesystemprocedural
WAhospital2008-07-28

Inquest into the Death of kidner

41y · Male·Head Injury in a Man with Acute Alcohol Intoxication; basal skull fracture with …

Ronald Gregory Kidner, 41, died from a basal skull fracture and severe head trauma on 25 October 2004, four days after falling at a recreation club while acutely intoxicated. He presented t…

emergency medicinegeneral medicinediagnosticcommunicationalcohol
VIChome2024-03-07

Finding into death of Claire Louise Carroll

45y · Female·Neck compression secondary to hanging

Claire Louise Carroll, 45, died by hanging while experiencing severe untreated psychotic symptoms including auditory hallucinations, paranoid delusions, and persecutory ideation. She had complex mental health diagnoses (…

psychiatrygeneral practicesystemcommunicationclonazepam
VIChome2021-05-05

Finding into death of Aisha Devi Beck

39y · Female·Gunshot wound to the head

A 39-year-old woman with brief psychotic disorder experiencing suicidal and homicidal ideation killed her 4-year-old daughter and herself. She had been diagnosed with psychosis in 2015, treated with olanzapine, and disch…

psychiatrygeneral practicecommunicationsystemolanzapine
QLDcommunity2019-08-02

Ms D - Non-inquest findings

47y · Female·Overdose of hydromorphone

…s or maintain adequate daily monitoring. The coroner identified significant deficiencies in suicide risk assessment policies, inter-agency communication, domestic violence training, and medication management across both …

psychiatrygeneral practicediagnosticcommunicationhydromorphone
VIChospital2026-01-08

Finding into death of Malakai Cross-De Jesus

0y · Male·Complications following forceps delivery

… min, prolonged labour, multiple pulls) yet scalp observations were delayed due to CPAP bonnet obscuring assessment; (3) early recognition of SGH would have allowed earlier tailored resuscitation and optimized chances of…

obstetricsneonatologydiagnosticcommunicationbenzylpenicillin
VIChome2021-05-05

Finding into death of Aziza Beck

3y · Female·gunshot wound to the head

A 3-year-old girl was killed by her mother, who was experiencing a severe psychotic episode with suicidal and homicidal ideation. The mother had a history of Brief Psychotic Disorder (diagnosed 2015), was on olanzapine 1…

psychiatrygeneral practicecommunicationsystemolanzapine
VIChome2017-07-12

Finding into death of Risto Pedevski

79y · Male·Head and neck injuries from blunt force trauma

…by mental health services to adequately assess and manage risks posed to family members; inadequate risk assessments at discharge from Werribee Mercy Hospital in June 2013; poor information-sharing between mental health …

psychiatrygeriatric medicinediagnosticcommunicationantipsychotic medication
NSWhospital2017-06-06

Inquest into the death of Helen Ashburn

46y · Female·Prolonged effects and complications of a head injury, with upper airway obstruct…

Helen Ashburn, a 46-year-old woman with history of alcohol use, coagulopathy and seizures, died from prolonged effects of a severe head injury sustained on 25 October 2011. She presented to Kempsey Hospital with extensiv…

emergency medicineneurosurgerycommunicationdiagnostic
NTmental health2019-09-13

Inquest into the death of Daniel Alexander Bleaney

37y · Male·blunt force injuries to the head and chest from jumping off an 8.65 metre roof

… overboard. He was rescued and admitted involuntarily to Cowdy Ward, an open psychiatric ward, following assessment in the ED. He was assessed as highest risk for suicide but placed on 15-minute observations rather than …

psychiatryemergency medicinesystemdiagnosticdiazepam
QLD2011-11-24

Choi, Seongeun; Park, Sang Won

Unknown·Ms Choi: hypoxic brain damage due to drowning/immersion due to rafting accident;…

…nt understandings of traffic management at the rapid. The coroner recommended formal rapid-by-rapid risk assessments identifying collision hazards and specific control measures, with external expertise to strengthen RnR'…

emergency medicineintensive caresystemcommunication
SAcommunity2001-10-05

Coroner's Finding: BEDNAREK Shantel Lisa

7y · Female·Multiple abdominal injuries including traumatic rupture of the liver and stomach…

…ne month after a severe hypoglycaemic episode and seizure, and certified him fit to drive without proper assessment; (5) missed medical appointments following a serious hypoglycaemic episode requiring hospitalization sho…

endocrinologyemergency medicinediagnosticcommunicationinsulin
VIChome2024-01-25

Finding into death of Lachlan John Howe

13y · Male·Hanging

Lachlan John Howe, aged 13, died by hanging at his home on 18 May 2018 after being transported to Royal Children's Hospital. He had experienced significant family violence from his father, including emotional abuse, cont…

paediatricspsychiatrycommunicationsystem

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