Coronial

123 results for x-ray imaging

VIChospital2017-06-27

Finding into death of Deborah Jane Parker

61y · Female·aspiration pneumonia

…een her death and her status as a person in care, and found care provision reasonable and appropriate. No imaging (chest X-ray) was documented during the inter-hospital period despite recurrent respiratory symptoms in a…

emergency medicinegeneral practicediagnosticantibiotics
SAhospital2019-05-31

Coroner's Finding: CHAPLIN Gray Clyde

81y · Male·multi-organ failure complicating multiple right-sided rib fractures due to a fal…

…a 1.5m ladder fall. Initial assessment at a rural hospital on day one was appropriate. However, when chest X-rays on day two revealed 9 rib fractures, the treating general practitioner failed to appreciate the seriousne…

general practiceemergency medicinediagnosticdelaymorphine sulphate
VIChospital2024-04-11

Finding into death of Mark Andrew Spillane

58y · Male·Septic shock secondary to intra-abdominal collections as sequelae of osteomyelit…

…sed by osteomyelitis/discitis of the spine. He initially presented with a foot bone infection detected on imaging in May 2023. Subsequent imaging revealed large bilateral psoas and retroperitoneal collections with L5/S1…

infectious diseasesgeneral medicine
SAhome2014-09-05

Coroner's Finding: HARRISON Noah Alexander Edward

<1y · Male·unascertained; possibly asphyxiation related to sleeping position

…rrangements. At prior hospital admission on 17 September 2010 for fever and reported haematemesis, a chest X-ray revealed healing rib and humerus fractures suggestive of inflicted injury, but these were not recognised b…

emergency medicinepaediatricsdiagnosticcommunication
VIChospital2018-06-18

Finding into death of Giuseppe Costa

75y · Male·Right haemothorax complicating intercostal catheter insertion for the treatment …

Giuseppe Costa, 75, died from right haemothorax following intercostal catheter insertion for pleural effusion drainage. Critical failures in clinical management included: inadequate documentation of pleural fluid drainag…

respiratory medicinegeneral medicineproceduralcommunicationnebivolol
NThospital2000-10-31

Inquest into the death of Marcio Jose Lay Nheu

26y · Male·Closed head injury with extradural and subdural haemorrhage resulting from a sku…

…alking), he was prematurely discharged after 40-50 minutes of assessment into police custody without CT or X-ray imaging. He was returned to the police watchhouse where he remained unresponsive. The following morning he…

emergency medicineneurosurgerydiagnosticcommunicationtemazapam
SAaged care2024-06-19

Coroner's Finding: Murphy, Phillip Robin

76y · Male·right lower lobe pneumonia on a background of frontotemporal dementia, chronic o…

… home. He was admitted to hospital on 9 February 2022 with post-fall pain, sweating, and irregular pulse; imaging revealed early lung consolidation and acetabular fracture. He was treated with antibiotics and analgesia …

geriatric medicinepalliative care
SAhospital2010-09-27

Coroner's Finding: ORMEROD Madison Hayley

4y · Female·consequences of incarcerated congenital left diaphragmatic hernia

…nd did not adequately consider the vomiting as potentially serious, declining to order abdominal or chest imaging. When presenting to hospital in collapse, she was discharged after brief assessment without imaging or ad…

general practicepaediatricsdiagnosticdelay
SAaged care2026-06-19

Coroner's Finding: Fowle, Colleen Margaret

78y · Female·urinary tract infection and pneumonia on a background of facial fractures and de…

… eye laceration. The fractures were not identified during her initial hospital assessment as radiological imaging was not deemed necessary, despite head injury. She was discharged and gradually deteriorated with declini…

general practicegeriatric medicinediagnostic
NSWhospital2015-06-24

Inquest into the death of Giovanni TRIPODI

91y · Male·The combined effects of chest injuries and old age

A 91-year-old man presented to the ED after a motor vehicle crash with chest pain. While imaging revealed abnormalities, ED staff and a junior registrar considered these to be old fractures rather than …

emergency medicineradiologydiagnosticsystemparacetamol
QLDhospital2009-10-08

Kerkvliet, Kristen

1y · Female·acute myocardial infarction secondary to Kawasaki's Disease

…Initial clinical assessment by multiple doctors found no obvious cardiac abnormality on examination. Chest x-rays were reviewed by the treating doctor (non-radiologist) who noted pneumonia and possible cardiac enlargeme…

paediatricsgeneral practicediagnostic
QLDhospital2019-12-05

Skilton, Robert Douglas

73y · Male·Lung cancer (squamous cell carcinoma)

…ed advanced lung malignancy and referred him to hospital. An administrative delay of 9 days in processing imaging did not affect outcome. At Princess Alexandra Hospital, palliative care was promptly engaged with broncho…

respiratory medicineoncologysystemmorphine
TAShome2019-06-26

Coroner's Finding: Lukendlay, Charlotte (OM) Findings

<1y · Female·global hypoxic brain injury caused by prolonged cessation of breathing arising f…

An 11-week-old healthy infant died from global hypoxic brain injury following cardiac arrest at home. Multiple rib fractures and a clavicle fracture in various stages of healing indicated repeated non-accidental trauma i…

paediatricsintensive caresystem
VIChospital2021-04-14

Finding into death of Mark James O'Brien

56y · Male·Complications of atraumatic bilateral femoral fractures (repaired) during a seiz…

…cal fracture to his left femur, sustained during a seizure on 15 June 2019, was not identified on initial imaging on 17 June 2019, despite clinical concerns about pain and reluctance to mobilise. The fracture went undia…

orthopaedic surgerygeriatric medicinediagnosticcommunicationsodium valproate
QLDhospital2010-03-05

Hockey, Barry John

58y · Male·adenocarcinoma of the right lung

… Unit. He presented in November 2007 with respiratory symptoms initially misdiagnosed as infection; chest imaging and pleural fluid analysis eventually confirmed lung cancer. He received appropriate multidisciplinary ca…

respiratory medicineoncologyoxycodone
NSWhospital2019-12-09

Inquest into the death of Douglas ANDERSON

84y · Male·staphylococcus aureus sepsis complicating metastatic malignancy

…alth assessment identified multiple comorbidities including heart disease, dementia, and hypertension. CT imaging revealed pleural effusion and gastro-oesophageal mass; a chest drain was inserted and palliative care ini…

emergency medicinegeneral medicine
SAhospital2003-11-05

Coroner's Finding: MARTIN Julie Anne

38y · Female·peritonitis with septic shock secondary to perforation of the gastrointestinal t…

… difficulty. Had the receiving team known of the difficult reinsertion, they might have pursued abdominal imaging earlier. (5) Poor communication between facilities and between clinical handovers contributed to delayed …

anaesthesiaemergency medicinediagnosticcommunicationsuxamethonium
VIChospital2026-03-19

Finding into death of Richard Watson

62y · Male·Aspiration pneumonia complicating epilepsy in the setting of Down syndrome

…a and seizures. On 3 April 2024, he presented with a seizure, respiratory arrest requiring CPR, and chest imaging consistent with aspiration pneumonia. He deteriorated despite antibiotic treatment and was transferred to…

emergency medicinerespiratory medicine
WAhospital2022-03-28

Inquest into the Death of Morgan John EDWARDS

31y · Male·Complications in association with intestinal volvulus

…ospital ED on 14 August 2018 without definitive diagnosis despite elevated respiration rate, unsuccessful imaging attempts, and elevated lactate levels. He was sent home unaccompanied by a care worker to a group home wi…

emergency medicinegastroenterologydiagnosticcommunication
WA2025-03-27

Inquest into the Death of Travis Dion BAUMGARTEN

48y · Male·Complications of human immunodeficiency virus infection with terminal palliative…

Travis Dion Baumgarten was a 48-year-old Aboriginal man serving a prison sentence at Acacia Prison in Western Australia who died on 5 December 2022 from complications of untreated HIV/AIDS. After HIV diagnosis in 1994, h…

infectious diseasesgeneral medicine

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