Coronial
TAS2024-12-18

Coroner's Finding: Twining, Laurence Charles

70y · Male·Trauma of the chest and abdomen; severe chest injuries including multiple bilate…

…ar day on a dry road with no mechanical defects. Investigation concluded the most likely cause was driver fatigue/falling asleep. There are no clinical lessons for healthcare professionals in this case, as death resulte…

TAScommunity2024-05-17

Coroner's Finding: Ferguson, Jalissa Maree

29y · Female·Multiple head, neck, trunk, pelvic and limb injuries sustained in a single vehic…

…e speed (95+ km/h) on the East Tamar Highway while under the influence of methylamphetamine and cannabis, fatigued, and without a seatbelt. She crossed double white lines, lost control, struck a concrete drain, and was …

methamphetamine
SA2000-07-07

Coroner's Finding: BAULDERSTONE Andrew Grant

37y · Male·Multiple injuries including lung lacerations and contusions, multiple rib fractu…

…luded: manufacturing defects in anchor hooks (141 of 251 hooks lacked specified 5mm radius bend, reducing fatigue life 2.5-fold); inadequate quality control of welding; and structural stress from major kiln design chang…

occupational and environmental healthforensic medicinesystemprocedural
VICcommunity

Finding into death of Gordon Edward Wright

Male·Drowning

…don Edward Wright drowned after capsizing his boat at Manns Beach Entrance on 18 November 2009. He became fatigued in the water and was unable to prevent aspiration. The coroner found this death was likely preventable h…

VIChome2022-11-21

Finding into death of Ms AA

57y · Female·Positional asphyxia

…for many aged care supports as a temporary visa holder. The coroner found BB was experiencing significant fatigue and stress from informal caregiving. This case highlights systemic failures in supporting informal carers…

geriatric medicineemergency medicine
SAcommunity2002-03-07

Coroner's Finding: GIBBONS Leith

17y · Male·incineration

…moglobin saturation was low, excluding inhalation as a contributing factor. The accident cause was likely fatigue and inattention. The coroner found no preventable factors and commended the rescue attempts and emergency…

forensic medicineemergency medicine
TAScommunity2019-09-10

Coroner's Finding: Mwarabu, Alice

33y · Female·multiple blunt injuries sustained in a motor vehicle crash

…ting factors. Toxicological analysis was negative for drugs and alcohol. The coroner found no evidence of fatigue despite Mrs Mwarabu having worked a night shift ending at 7am. No clinical or medical factors were identi…

VIC2010-08-03

Finding into death of George Panayiotis

48y · Male·Multiple injuries sustained in a motor vehicle collision (passenger)

…buted—excessive speed (100 kph in a 90 kph zone), wet unfamiliar conditions, and poor road surface—driver fatigue was identified as the precipitating factor. The driver had worked excessive hours: over 12 hours daily fo…

systemdelay
NSWhome2016-01-20

Inquest into the death of Leonie Margaret Philpott

47y · Female·unascertained - natural causes

…cervical cancer (treated), and possible recurrent Barmah Forest Virus infection. Recent symptoms included fatigue and headaches. Her husband reported she may have had sleep apnoea but without evidence of cardiac damage.…

pathologygeneral practiceibuprofen
QLD2018-12-21

Wills, Michael Vincent

Male·Multiple injuries due to helicopter crash caused by in-flight failure of rear st…

… in Central Queensland. Investigation revealed the rear stabiliser assembly failed in-flight due to metal fatigue caused by excessive vibration from a defective tail rotor gearbox output bearing. The gearbox exhibited e…

designsystem
TAS2023-09-15

Coroner's Finding: Briggs, Phillippa Helene

51y · Female·Multiple (head, neck, spine and chest) injuries sustained in a motor vehicle acc…

…er a clockwise yaw and rollover. The coroner found no defects in the road, vehicle, or driver impairment. Fatigue and microsleep could not be excluded as contributing factors but could not be confirmed post-mortem. This…

QLD2018-03-27

Brown, Stephen Ross

54y · Male·Pulmonary embolus

… Feeds truck suffered catastrophic suspension failure when both right front leaf springs fractured due to fatigue cracks developed from driving on rough country roads. The primary leaf spring failed first, placing exces…

emergency medicinetrauma surgery
VIChome2017

Finding into death of Harold George Nolan

73y · Male·Stab wound to the neck

…eep at home. Ms Nolan was his full-time carer following his 2013 stroke and was experiencing severe carer fatigue, mental health deterioration, financial stress, and paranoid thinking. She had been referred to a private…

general practicepsychiatrycommunicationdelayantidepressants
VIC2015-07-27

Finding into death of Michael John Jonson

48y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

…d was being towed on three wheels with an overload of approximately 1450kg ATM. The drawbar failed due to fatigue crack propagation accelerated by the three-wheel configuration and excessive loading, causing the trailer…

forensic medicinetrauma surgerysystemprocedural
NSWcommunity2018-04-11

Inquest into the death of Brendan Vickery

20y · Male·drowning

…immer who appeared fit and well before jumping. After his initial jump, witnesses observed him expressing fatigue and difficulty swimming, despite having been a good swimmer. Evidence suggests he likely inhaled water wh…

emergency medicinepathology
QLD2006-11-15

Hogan, Kevin James and Hogan, Winifred Therese

Kevin James Hogan: spinal and chest injuries due to motor vehicle incident, with…

…o prevent future deaths, including reducing speed limits from 100 to 80 km/h, installing warning signage, fatigue bumps, and cat's eye reflectors. The case highlights the importance of road infrastructure design and sig…

VICaged care2025-05-22

Finding into death of Veronica Lesley Roberts

75y · Female·Ischaemic heart disease in the setting of unstable type 2 diabetes mellitus and …

…se despite an electronic alert being overridden. Contributing factors included system design flaws, alarm fatigue, and staff knowledge gaps. While the coroner could not definitively prove the medication error caused dea…

geriatric medicinegeneral medicinemedicationsystemglargine insulin
TAS2023-09-01

Coroner's Finding: Hunt, Paul George; Reynolds, Paul James; Darke, Simon Graham; Cooke, Robert Anthony

Male·Hunt: self-inflicted gunshot wound to head; Reynolds: self-inflicted gunshot wou…

…reated severe PTSD from cumulative trauma exposure. The coroner identified failures in welfare protocols, fatigue management policies, early PTSD detection, and the handling of officers during professional standards inv…

psychiatrypsychologysystemcommunicationpseudoephedrine
TAS2022-10-19

Coroner's Finding: EL de-identified

32y · Male·Blast injuries including extensive subarachnoid haemorrhage and pulmonary haemor…

A 32-year-old experienced mechanic died from blast injuries sustained when a damaged truck tyre he was inflating exploded under pressure. The tyre had pre-existing sidewall damage from previous impact and was being infla…

proceduralsystem
VICcommunity2025-02-06

Finding into death of Baran Yalcin

29y · Male·Injuries sustained in a motor vehicle collision (bicycle rider)

…rns about safety risks and working conditions for food delivery workers, including economic pressures and fatigue.

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