Coronial

428 results for physical assessment

VIChospital2026-02-27

Finding into death of PDR

78y · Male·Acute pancreatitis

A 78-year-old man with a long history of mental illness and multiple chronic physical conditions died from acute pancreatitis on 12 May 2025, nine days after presenting with nausea and vomiti…

emergency medicinepsychiatryolanzapine
VICmental health2015-02-26

Finding into death of Paul Bernard Finck

47y · Male·pulmonary thromboembolism and deep vein thrombosis

Paul Finck, 47, an involuntary psychiatric patient with schizophrenia, died from pulmonary thromboembolism and deep vein thrombosis while admitted to the psychiatric ward. He presented with fever, tachycardia, elevated C…

psychiatryemergency medicinearipiprazole
QLDaged care2008-09-25

Warren, Michael

64y · Male·Sepsis and lung collapse precipitated by burns to 35% of body sustained while sm…

…lp due to aphonia, and his clothing caught fire on 28 June 2004. Key clinical lessons: (1) active safety assessment of smoking risks must occur for patients with diminished physical capability, including neurological dis…

neurologyemergency medicinediagnosticsystem
VIC2017-10-31

Finding into death of Andrew John Harman

49y · Male·Complications of heatstroke; Hyperthermia

…ded dirt bike tour in Hawaii. He consumed significant alcohol the previous day, then engaged in strenuous physical activity in warm, humid conditions (28-29°C) while wearing heavy protective equipment. He struggled early…

emergency medicineintensive caredelay
VICcommunity2018-03-14

Finding into death of C P

59y · Female·Gunshot injuries to the head

…West Footscray, Victoria. She was shot by her partner, Philip Bracken, following an escalating pattern of physical and emotional family violence throughout their relationship. CP had experienced abuse since childhood, su…

psychiatrydiagnosticcommunicationcitalopraam
VICcommunity2025-11-10

Finding into death of Ayman Peter Fatho

31y · Male·Gunshot injury to the chest

…ed with the deceased's ex-partner. The shooter, fearing for his life after months of harassment including physical assault and threats, obtained an illegal firearm and discharged it in self-defence during a high-speed pu…

methamphetamine
SAhome2016-05-05

Coroner's Finding: MITTON Rodney Lyle

63y · Male·coronary artery thrombosis

…treating resident doctor and attributed to a known long-standing complication of previous oesophagectomy. Physical examination was reassuring, blood work was normal, and leave was granted progressively. The coroner found…

psychiatrycardiologyolanzapine
QLD2010-10-08

Barker, Jeremy Dylan

27y · Male·Hanging

…atient in an area with accessible hanging points despite prior staff warnings about this risk; inadequate physical observation (required 15-minute checks were not performed in person after 2:00pm, relying instead on CCTV…

psychiatrycorrectional healthcommunicationsystemcarbamazepine
VIChome2020-05-28

Finding into death of David Bardho

53y · Male·Multiple gunshot wounds to the head

…o return to the property, but returned to pack belongings. When Bardho arrived home earlier than usual, a physical altercation ensued during which McSweeney believed Bardho was threatening him with a knife. The coronial …

WAhospital2016-02-05

Inquest into the Death of Pauline Margaret DODD

51y · Female·Ischaemic heart disease

… valve damage requiring prosthetic replacement. She presented with an infected breast lesion but resisted physical examination due to severe aversion to touch during acute psychiatric crisis. Cardiology input was sought …

psychiatrycardiologydiagnosticolanzapine
VICcommunity2013-06-21

Finding into death of Dennis Anderson

47y · Male·Unascertained natural causes, probably sudden cardiac arrhythmia

… weight management, and a poorly designed clip on the abalone bag. The excessive weight created insidious physical and mental stress, reducing his capacity to respond to difficulties. Evidence showed he used almost all h…

systemcommunication
TAShospital2021-07-27

Coroner's Finding: Menzies, Mervyn Roy

Male·aspiration pneumonia

Mervyn Roy Menzies, a 60+ year old man with intellectual and physical disabilities, died of aspiration pneumonia at Royal Hobart Hospital on 12 July 2020. He presented on 6 Ju…

emergency medicinegeneral medicine
NSWaged care2018-09-25

Inquest into the death of Melissa STANDEN

13y · Female·Hanging

Melissa Standen, a 13-year-old with profound physical and cognitive disabilities (mosaicism), died from hanging at Westmead Children's Hospital after falling f…

paediatricsoccupational therapydiagnosticsystem
QLDcommunity2017-03-13

MT - Non-inquest findings

67y · Male·coronary artery atheroma against a background of diabetes mellitus

…r than drowning. For clinicians: this case highlights the importance of pre-activity cardiovascular risk assessment in patients with multiple risk factors (age, diabetes, smoking) before strenuous activities. Patients wi…

cardiologyforensic medicine
WAmental health2011-04-21

Inquest into the Death of Barnes

50y · Female·acute heart failure in association with acute on chronic obstructive airways dis…

Donna Lillian Barnes, a 50-year-old woman with chronic schizophrenia and multiple physical comorbidities including morbid obesity, asthma, and poor mobility, died of acute heart failure associated…

psychiatrygeneral medicinecommunicationsystemantibiotics
VIC1996-09-02

GALLAGHER GREEN Kevin

39y · Male·neck injuries from being crushed between a hydraulic ram and hydraulically opera…

…chinery commissioning or subsequent audits despite adequate hazard identification procedures existing; no physical guarding was provided for the hidden danger point; training was fragmented between operators and maintena…

proceduralsystem
VICmental health2025-07-14

Finding into death of Maxwell Bernard Howard

84y · Male·Bronchopneumonia in the setting of pulmonary emphysema and hypertensive heart di…

…and bipolar disorder, with poor medication compliance from 2018. He was non-compliant with care, refusing physical examination and vital sign checks in the hours before death. On the day of death, he complained of abdomi…

psychiatryemergency medicinecarbamazepine
VIChospital2024-03-19

Finding into death of Craig Ashley Hill

53y · Male·Cardiomegaly in a man with obesity and chronic liver disease

…h serious mental illness have significantly elevated cardiovascular mortality risk and require integrated physical-mental health assessment, though in this instance his acute presentation did not allow for active managem…

psychiatrycardiologydiazepam
VIChome2022-05-23

Finding into death of Mr A

37y · Male·Stab wound to the left kidney

… Intervention Orders. Clinical lessons include: GPs should provide family violence referrals even without physical violence when patients report psychological distress and anxiety; Victoria Police risk assessments for FV…

general practiceemergency medicinesystemcommunication
WA- 14 March 2014

Inquest into the Death of Wayne ROSS

45y · Male·multiple injuries sustained from a 25-metre fall down an unprotected stope when …

…tion of the stope for surveying; the deceased's misinterpretation of these instructions; inadequate risk assessment procedures (the deceased assessed a high-risk task as 'low' risk); removal of bollard warnings without c…

occupational and environmental healthforensic medicinecommunicationsystem

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