Coronial
QLDcommunity2018-09-11

Giorgio, Pasquale

54y · Male·Ischaemic cardiomyopathy following a period of restraint on a background of morb…

…iousness, foam from mouth/nose, inadequate breathing) while in the police van, but was not removed or given CPR until a senior officer arrived. Clinical experts noted officers lacked sufficient training to recognise acu…

emergency medicineforensic medicinediagnosticcommunicationflupenthixol
WAhome

Inquest into the death of Nicole Emily BICKNELL

18y · Female·Acute Alcohol Toxicity with Early Pneumonia and Aspiration

…ts, developing early pneumonia. Approximately 2-3 hours later she was found unresponsive and not breathing. CPR was initiated at home then continued by paramedics and hospital staff, but resuscitation was unsuccessful d…

toxicologyemergency medicinedelaysystemalcohol
TAScommunity2022-12-07

Coroner's Finding: Triffett, Brendan

40y · Male·cardiac arrhythmia due to cardiovascular disease

…tole with less than 10% survival probability even in optimal circumstances. The coroner commended the rapid CPR response by pool staff and found no preventable factors, making no recommendations. The case demonstrates s…

cardiologyemergency medicineamitriptyline
VIC2016-04-14

Finding into death of Miriam Ralph

49y · Female·Unascertained (natural)

…d requested her Ventolin inhaler. Four staff members provided first aid, called an ambulance, and commenced CPR. Despite resuscitation attempts by paramedics, she died. The cause was determined as unascertained natural …

emergency medicineforensic medicinebenztrop
QLDaged care2009-05-05

Hoy, Raleigh

41y · Male·Dilated cardiomyopathy

…include: (1) inadequate staff training and numbers led to delayed emergency response and failure to perform CPR; (2) poor communication between treating doctors and care facility regarding medication compliance and moni…

psychiatrygeneral practicecommunicationsystemclozapine
VICcommunity2023-09-07

Finding into death of Angelo Anthony Gioscio

55y · Male·cardiac arrest in the setting of methylamphetamine toxicity, with possible serot…

…ly, used minimal force to restrain him safely (placing him in recovery position), and immediately commenced CPR when he lost consciousness. The coroner found police actions professional, appropriate, and in accordance w…

forensic medicinetoxicologymethamphetamine
WAcommunity2024-04-26

Inquest into the Death of Warren John BULLOCK

49y · Male·Cardiac arrhythmia in a man with methylamphetamine effect and cardiomegaly

…c event triggered by physical exertion and drug use rather than police action. Police immediately initiated CPR to good standard. The coroner found no police fault or contribution to death. The case highlights that unde…

methamphetamine
NSW2025-02-24

Inquest into the death of Alfonso Ceniccola

82y · Male·Ischaemic heart disease due to coronary atherosclerosis with significant contrib…

…ended on the floor, failed to maintain constant electronic monitoring during a critical period, and delayed CPR by 15 minutes. While the fatal cardiac event could not have been predicted, expert evidence suggests earlie…

cardiologycorrectional healthsystemcommunication
SAcommunity2024-01-23

Coroner's Finding: Chua, Ardebby Oh

41y · Female·salt water drowning

…cy vests despite availability; critically, 18-30 minutes elapsed before retrieval to the boat for effective CPR on a hard surface—delaying resuscitation that should have occurred within minutes. No practised in-water re…

emergency medicinediving medicinesystemcommunication
QLD2013-09-24

Emerton, Andrew John Joseph

43y · Male·Coronary Atherosclerosis

…e called for help reporting shortness of breath and was found unconscious within minutes. Despite immediate CPR by correctional officers and paramedics, he could not be revived. Autopsy revealed severe coronary atherosc…

cardiologyemergency medicinequetiapine
VIC2025-05-20

Finding into death of Jessica Anne Katgert

41y · Female·Cardiomegaly

…een custody and her natural death. Minor policy gaps in incident response were identified (cell key access, CPR initiation) but would not have altered the outcome as she was already deceased when discovered.

cardiologyinfectious diseasessystembuprenorphine
QLD2007-04-18

Thorpe, Geoffrey

47y · Male·Myocarditis

Geoffrey Thorpe, a 47-year-old fitter, collapsed and died suddenly at work while testing solenoids with electrical equipment. Initial suspicion of electrocution was thoroughly investigated through expert electrical testi…

pathologygeneral practicesystemsertraline
VICcommunity2018

Finding into death of Amanda Bourke

44y · Female·Drowning

…. A passing bystander rescued her but she had already inhaled water. Bystanders including a nurse performed CPR until paramedics arrived 21 minutes after the 000 call. The delay in emergency response was primarily due t…

systemalcohol
NSWhospital2022-09-26

Inquest into the death of Faithe Baxter

22y · Female·cardiac arrest of uncertain cause noting the existence of drug toxicity; the dru…

… respiratory distress the following morning, immediately called emergency services at 8:30 am and commenced CPR. Paramedics arrived within 8 minutes and achieved return of spontaneous circulation. The coroner found no e…

emergency medicineintensive caredelaymethamphetamine
QLD2026-03-31

Inquest into the death of Kyle James Gallagher

22y · Male·Airway obstruction due to laryngeal abscess and laryngeal chondronecrosis due to…

Kyle Gallagher, age 22, died from airway obstruction due to laryngeal abscess and chondronecrosis following a motorcycle accident. A CT scan on 13 July 2023 showed a critically narrowed (3mm) subglottic airway with suspe…

ENT surgeryradiologydiagnosticcommunicationdiazepam
VIChospital2023-11-08

Finding into death of K S

4y · Female·Drowning

…lapse of supervision. She was unable to swim and had not received water safety education. Despite immediate CPR by bystanders and paramedics, she suffered devastating hypoxic brain injury and died two days later in ICU.…

emergency medicineintensive caresystem
SAhospital2020-11-03

Coroner's Finding: WHISKEY Louise Kitty

51y · Female·community acquired pneumonia

Louise Kitty Whiskey, a 51-year-old Aboriginal woman with chronic alcohol misuse, cirrhosis, and recurrent respiratory infections, died from community-acquired pneumonia at Royal Adelaide Hospital. She was admitted on 23…

intensive carepsychiatrysystemnoradrenaline
QLDhospital2013-04-16

Hornby, Geoffrey John

58y · Male·Respiratory failure due to or as a consequence of Chronic Obstructive Pulmonary …

…ping cardiac arrest on 17 March 2010. Critical delays occurred in recognising cardiac arrest and commencing CPR, with chest compressions not begun until approximately 1 minute 37-55 seconds after pulse loss. The coroner…

respiratory medicineemergency medicinecommunicationdelaysalbutamol
ACT2019-06-26

Inquest into the death of Mark Anthony O’Connor

40y · Male·Multiple drug toxicity, being either an overdose due to methylamphetamine alone,…

…exander Maconochie Centre. Emergency response was immediate and appropriate—correctional officers initiated CPR within seconds, ACT Health staff arrived within three minutes with bag-valve-mask ventilation, and ambulanc…

emergency medicinetoxicologymethamphetamine
VICaged care2023-05-15

Finding into death of Jennifer Mary Thomas

65y · Female·Unascertained

…ied in disability residential care. She became unresponsive in her wheelchair and staff performed emergency CPR after lifting her to the floor. Post-mortem examination revealed fractures to her left humerus and right fe…

geriatric medicinedisability medicinesodium valproate

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