Coronial

215 results for emergency triage

TAShospital2021-02-05

Coroner's Finding: Lattimer, Joseph Aaron

37y · Male·hypoxic encephalopathy due to asphyxia from hanging

Joseph Aaron Lattimer, aged 37, presented to the Royal Hobart Hospital Emergency Department at 5:02am on 10 July 2016 in mental health crisis with suicidal ideation, correctly triaged a…

emergency medicinepsychiatrysystemdelayalcohol
VICcommunity2010-04-12

Finding into death of Veronica Campbell

23y · Female·complications of ruptured ectopic pregnancy with massive intra-abdominal haemorr…

…ons include: classification of ectopic pregnancy cases should reflect criticality from the outset; initial triage and communication with receiving hospitals must be clear and timely; rural facilities need pre-agreed prot…

emergency medicineobstetricscommunicationsystemmorphine
VIChome2024-05-13

Finding into death of Victor Dale Fenech

56y · Male·complications of metastatic colorectal carcinoma

…old experiencing homelessness, died from complications of metastatic colorectal carcinoma. He made three emergency calls over two days before his death, but ambulances did not attend the first two calls. Key issues incl…

emergency medicineparamedicinecommunicationsystemcocaine
QLDhospital2013-10-28

Loveday, Marcia Joy

74y · Female·Cardio-renal failure due to gangrene of calculous gallbladder, with significant …

An elderly woman with a documented penicillin allergy, wearing a MedicAlert bracelet, presented to emergency with respiratory distress and chest pain. She was administered intravenous Ampicillin without allergy ve…

emergency medicineintensive carediagnosticmedicationampicillin
NSWhospital2025-08-14

Inquest into the death of Wilfred Whippy Williams

45y · Male·Diabetic ketoacidosis with multi-organ failure caused by pneumonia

…es and schizophrenia presented to Cowra District Hospital ED with lethargy, cough and fever. Despite being triaged as category 2 (urgent) with abnormal vital signs including tachycardia, he left before seeing a doctor an…

emergency medicineendocrinologycommunicationdiagnosticmetformin
VIChospital2024-08-08

Finding into death of Alan Edward Stewart

70y · Male·haemoperitoneum and ruptured spleen following colonoscopy

…ge information was vague about internal bleeding symptoms and failed to clearly distinguish when to call emergency services versus a GP. When Mr Stewart's wife called Nurse-on-Call that evening reporting breathlessness …

gastroenterologyemergency medicinediagnosticcommunication
WAhome2007-07-27

Inquest into the Death of Chubby

64y · Female·Acute bronchopneumonia in a woman with liver failure

…ning. The coroner found the ambulance call-out protocol inadequate and noted that with the new Perth-based triage system then being implemented, an ambulance would almost certainly have been dispatched. Death was by natu…

general medicinecardiologycommunicationdiagnostic
ACThospital2023-03-08

Inquest into the death of Brontë Haskins

23y · Female·Hypoxic-ischaemic brain damage due to self-inflicted hanging with intention of t…

…e documented suicidality in custody, and loss of opportunity when Access Mental Health failed to correctly triage a call from her mother describing acute psychosis. While no individual clinician was culpable, the coroner…

psychiatryemergency medicinesystemdelayheroin
VIChospital2024-11-22

Finding into death of RD Z

11y · Male·complications of bowel obstruction in the setting of chronic constipation

…e ED on 24 March with severe abdominal distension, lactic acidosis, and signs of shock. Critical gaps in emergency care included incomplete triage assessment, absent blood pressure recordings throughout ED stay, and pla…

gastroenterologypaediatric surgerydiagnosticcommunicationmacrogol
VIC2023-09-12

Finding into death of Nicola Jane Stephens

46y · Female·Single stab injury to the abdomen

…ulance Victoria Duty Manager based on caller information. The case highlights the importance of accurate emergency call triage and the potential consequences of downgrading life-threatening presentations. No clinical ma…

alcohol
VIChome2024-08-08

Finding into death of Alan Edward Stewart

70y · Male·haemoperitoneum secondary to ruptured spleen following colonoscopy

… Post-discharge advice was inadequate, failing to list symptoms of internal haemorrhage; (2) Nurse-on-Call triage nurse failed to correctly assess airway-breathing-circulation compromise when Mr Stewart presented with br…

gastroenterologyemergency medicinecommunicationsystemparacetamol
TAShospital2021-08-26

Coroner's Finding: PY

0y · Unknown·sepsis leading to multiple organ failure syndrome

…ate with congenital heart defect presented to the ED with fever and vomiting on 20 September 2019. Initial triage as Category 3 was inappropriate; the child required urgent assessment. The ED intern saw the patient after…

paediatricsemergency medicinediagnosticdelayparacetamol
NSWhome2026-04-01

Inquest into the death of EJJ

39y · Male·Hanging

…entified: understaffing at Nepean PAC leading to unanswered phone calls, lack of centralised mental health triage for police welfare check calls, and limited co-responder models. The coroner endorsed rolling out co-respo…

psychiatryforensic medicinecommunicationsystemdiazepam
VIChome2024-04-23

Finding into death of Robert Norman Spencer

59y · Male·ischaemic heart disease in the setting of chronic ethanol use

…t Spencer, 59, called 000 at 4:27 am reporting weakness and inability to mobilise following a fall. He was triaged as Code 3 (non-urgent) and underwent secondary triage call-back attempts without success. An ambulance wa…

emergency medicineparamedicinesystemdelay
VIChospital2024-10-10

Finding into death of Makayla Lee Wadeson

9y · Female·Streptococcus pneumoniae and Candida albicans pneumonia and empyema in a girl wi…

…deson, a 9-year-old autistic girl with ulcerative colitis on immunosuppressive therapy, presented to the emergency department with ear infection symptoms on 29 July 2022. She was triaged Category 4 and discharged with a…

emergency medicinepaediatricsdiagnosticsystemcefalexin
VIChome2019

Finding into death of Rachel Naomi Mihail

36y · Female·Nicotine toxicity

…anxiety, and agoraphobia, ingested liquid nicotine at home on 22 November 2017 after calling mental health triage expressing suicidal intent. The clinical lessons relate to the response to acute suicide risk. At 1:10am, …

psychiatrygeneral practicecommunicationsystemnicotine
WAhospital2016-09-28

Inquest into the Death of Donald Richard BROADRIBB

79y · Male·Bronchopneumonia and acute bronchiolitis

Donald Broadribb, 79, died of bronchopneumonia and acute bronchiolitis after presenting to York Hospital on 12 October 2012 with vomiting, cough, and abdominal pain. He was discharged after nurses focused on treating con…

emergency medicinegeneral practicediagnosticcommunicationhyoscine butylbromide
SAhospital2004-12-14

Coroner's Finding: O'NEILL Louise Kay

31y · Female·mixed drug toxicity (propoxyphene, fluvoxamine, and alprazolam)

…ug abuse died from mixed drug toxicity (propoxyphene, fluvoxamine, and alprazolam). She presented to the emergency department with a reopened wrist laceration and reported mild analgesia use, but had actually consumed a…

emergency medicinetoxicologydiagnosticcommunicationpropoxyphene
WA2017-05-12

Inquest into the Death of Arulselvam VELMURUGU

35y · Male·bronchial asthma

…ayed transfer to hospital from jetty, failure to immediately identify him at the processing centre using a triage system, disorganised medical equipment (non-functional oximeter, missing defibrillator), lack of clinical …

emergency medicinegeneral practicecommunicationsystemsalbutamol
QLDhospital2011-09-20

Anderson, John Clive

36y · Male·infective endocarditis

…itis on 25 March and again on 12 May, but the referral to Princess Alexandra Hospital general medicine was triaged as non-urgent (category B, 30-day appointment). The patient deteriorated rapidly in late May with pneumon…

general practicecardiologydelaycommunicationamoxicillin

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