Coronial

49 results for emergency alerting

NTPodcast2025-10-24

Inquest into the death of Ebony Thompson

1y · Female·hypoxic brain injury caused by pressure to the neck from entrapment on a loop-to…

Ebony Thompson, aged 22 months, died from hypoxic brain injury caused by neck entrapment in a loop-topped chickencoop gate at a childcare centre. She became trapped while standing on a tricycle attempting to view chicken…

paediatricsemergency medicinesystemcommunication
NSWcommunity2024-03

Inquests and Inquiries into the 2019/2020 NSW Bushfire Season - Volume 2

systemic inquiry into 2019-2020 NSW bushfire season deaths - no single death exa…

…he coroner made 26 recommendations addressing investigation protocols, inter-agency information sharing, emergency communications systems, aerial firefighting resources and coordination, fire prediction capabilities, ve…

systemcommunication
NSWhome2020-06-01

Inquest into the death of A P

2y · Female·drowning

… documented deterioration; and most significantly, an urgent referral from the treating GP on 9 September alerting the mental health emergency team to the mother's acute relapse was never actioned—no record was found and…

general practicepsychiatrycommunicationsystemtriflouperazine
VICcommunity2013-10-21

Finding into death of Matthew John Stubbs

13y · Male·chest and abdominal injuries sustained in collision between semi-trailer and tra…

…conspicuity for truck drivers and failure to replace incandescent lights with LEDs before the collision. Emergency response issues included tension pneumothorax development during air transfer. Lessons include improving…

emergency medicinetrauma surgerysystemdelay
NSWcommunity2017-05

lindt cafe findings-and-recommendations

Tori Johnson: executed by gunshot wound inflicted by Man Haron Monis; Katrina Da…

… stormed the café. Hostage Katrina Dawson was fatally struck by fragments from police gunfire during the emergency tactical action. Monis was killed by police. This major coronial inquest examined police response, negot…

psychiatryemergency medicinecommunicationsystem
VIC2013-10-21

Finding into death of Stephanie Louise Meredith

46y · Female·Multiple injuries sustained in collision between semi-trailer and train; tension…

…lack of robust human factors research informing safety systems, deficient trailer brake maintenance, and emergency response issues including inappropriate transfer of a trauma patient by fixed wing aircraft without crit…

emergency medicinetrauma surgerysystemdelaymorphine
VIChospitalPodcast2026-02-20

Finding into death of James Harilaos Tsindos

17y · Male·Hypoxic Ischaemic Encephalopathy Complicating Anaphylaxis

…ntified two key missed opportunities: (1) recognizing the wheeze as recurrent anaphylaxis and immediately alerting a doctor; and (2) administering IM adrenaline more promptly on deterioration. Expert opinion diverged on …

emergency medicineallergy and immunologydiagnosticcommunicationadrenaline (epinephrine) intramuscular
VIChome2025-12-19

Finding into death of Narisha Faye Cash

41y · Female·Combined Drug Toxicity (ethanol and benzodiazepine)

… died on 26 March 2020 from combined drug toxicity (ethanol and benzodiazepines) following an inadequate emergency services response to her mental health crisis. She called 000 expressing suicidal intent and reported co…

emergency medicinepsychiatrysystemcommunicationalcohol
QLD2009-01-27

Scholl, Philip Henry

42y · Male·multiple injuries sustained in aircraft crash resulting from port side wing tip …

Philip Scholl, an inexperienced microlight pilot with only 20 hours flight training, died in a crash near Mareeba on 20 October 2005. The aircraft T2-2776 was airworthy unfit due to degraded wing fabric, corroded cables,…

aviation medicineemergency medicinediagnosticsystem

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