Coronial
QLDhospital2017-09-02

ML - Non-inquest findings

71y · Female·Haemothorax and haemopericardium secondary to ruptured dissecting aneurysm of th…

…hypertension and prior myocardial infarction presented to emergency with sudden chest pain, jaw pain, and syncope. Aortic dissection was appropriately suspected and a contrast CT-aortagram was performed, which showed no…

emergency medicinecardiologydiagnosticsystemintravenous fluids
VIChospital2025-03-12

Finding into death of Robin Albert Banks

90y · Male·Pneumonia complicating injuries sustained in a motor vehicle incident

A 90-year-old man died from pneumonia following injuries sustained in a motor vehicle collision. He had multiple reportable medical conditions including atrial fibrillation, coronary artery disease, chronic kidney diseas…

general medicinegeriatric medicinecommunicationsystemdigoxin
VIChome2017-08-28

Finding into death of Tara Sue Love

22y · Female·Sudden Arrhythmic Death Syndrome

… blood pressure only once post-discharge. No cardiology referral was made despite episodes suggesting pre-syncope. The hospital lacked a formal ECG policy, resulting in inconsistent review and interpretation. Preventabl…

obstetricscardiologydiagnosticcommunicationlabetalol
WAhospital2023-11-29

Inquest into the Death of Samuel Edward ASHBY

46y · Male·Aspiration pneumonia in an obese man with a history of diabetes mellitus, obstru…

Samuel Edward Ashby, a 46-year-old prisoner with treatment-resistant schizophrenia, died from aspiration pneumonia complicated by clozapine effect. Key clinical lessons: (1) smoking cessation dramatically increases cloza…

psychiatrygeneral medicinediagnosticsystemclozapine
TAS2022-04-29

Coroner's Finding: Lavoipierre, Andre Marc

41y · Male·exsanguination (hypovolemic shock complicating acute blood loss) due to fistula …

Andre Marc Lavoipierre, age 41, died on 26 June 2019 from exsanguination due to internal bleeding (ureter-iliac artery fistula or steady renal/bladder bleed). He fell at his supported residential unit on the morning of d…

psychiatrygeneral practicecommunicationdelayfluoxetine
TAShospital2024-10-11

Coroner's Finding: Vieth, Karl Heinz

92y · Male·periprosthetic fracture of the left hip sustained from a fall from standing posi…

A 92-year-old man with complex cardiac history was admitted to Royal Hobart Hospital with chest pain and atrial fibrillation. He remained in the Emergency Medical Unit (EMU) for five days despite clinical deterioration, …

general medicineemergency medicinesystemdelaymelatonin
WAcommunity2007-05-11

Inquest into the Death of Robson

16y · Female·Adrenal insufficiency (Addison's Disease)

Emma Louise Robson, a 16-year-old female, died on 29 September 2004 from adrenal insufficiency (Addison's Disease), a treatable autoimmune condition. She presented with progressive fatigue, weight loss (from 48–50 kg to …

general practiceemergency medicinediagnosticsupervision_issue
NTcommunity2014-05-27

Inquest into the death of Benjamin Wilton

29y · Male·severe burns sustained in motor vehicle fire following collision

29-year-old Benjamin Wilton was killed in a horrific car fire following a rear-end collision with a vehicle driven by 67-year-old Robert Spencer on a Darwin highway. Spencer had suffered a stroke in 2003 with residual co…

neurologycardiologydiagnosticsystem
QLDhospital2015-07-28

Mills, Stephen John

57y · Male·Head injury from fall; with coronary atherosclerosis and complete heart block wi…

A 57-year-old man with bipolar disorder died from head injury following a fall at Toowong Private Hospital. Critical failures in falls risk management were identified: no formal falls risk assessment was completed on adm…

psychiatryneurosurgerysystemcommunicationseroquel xr

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