Coronial

859 results for brain injury

NT2018-02-07

Inquest into the death of Vernon Bonson

31y · Male·Self-inflicted hanging

Vernon Bonson, a 31-year-old Aboriginal man, died by self-inflicted hanging in Darwin Correctional Precinct on 25 August 2016. He was remanded in custody facing sexual assault allegations that appear to have originated f…

systemdelay
SAcommunity2011-05-12

Coroner's Finding: KILTIE Andrew

52y · Male·clozapine toxicity

Andrew Kiltie, 52-year-old Aboriginal man, died from clozapine toxicity on 26 December 2007. He had been on clozapine 400mg daily for 5 years with significant clinical benefit for aggressive behaviour and psychosis, enab…

psychiatrycardiologyclozapine
WAhospital2015-01-15

Inquest into the Death of Petra ZELE

28y · Female·hypoxic brain injury following cardiac arrest in association with pulmonary hype…

Petra Zele, a 28-year-old woman, died from hypoxic brain injury following cardiac arrest due to acute pulmonary embolism superimposed on chronic thromboembolic pul…

emergency medicinecardiologydiagnosticcommunicationyasmin
VICaged care2026-05-06

Finding into death of Cornelia Groot

87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…

An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…

geriatric medicineemergency medicinediagnosticcommunicationoxycodone
VICaged care2017-11-15

Finding into death of Garry Serve

82y · Male·Trauma related intracerebral haemorrhage

An 82-year-old man with dementia, cerebellar ataxia, and mobility limitations fell from his wheelchair down three concrete steps (480cm drop) while attending a hearing aid appointment at an off-site clinic. He sustained …

geriatric medicineemergency medicineproceduralcommunicationfluoxetine
TAS2017-08-11

Coroner's Finding: Hyland, Tobias Joseph

22y · Male·Blunt traumatic injuries of the head

…aved his life included: wearing a protective helmet (expert opinion suggests this may have prevented fatal brain trauma), proper tree felling training following Australian Standard 2727, formal risk assessment procedure…

system
NSWcommunity2008-01-24

Coroner's Finding: Vanessa Ann Anderson

16y · Female·Respiratory arrest due to the depressant effect of opiate medication

…rs to occur unchecked. Clinical lessons: always consult the primary team before changing analgesia in head injury patients; implement clear documentation and communication protocols; maintain proper supervision of junior…

neurosurgeryanaesthesiamedicationcommunicationoxycodone
VIChome2015-05-08

Finding into death of Divesh Sharma

5y · Male·unascertained

…erstanding of what constitutes family violence under Australian law; and multiple healthcare contacts post-injury provided no screening for suicide risk, homicide risk, or family violence despite cognitive decline and mo…

rehabilitation medicineneurologycommunicationsystemchloroform
QLDcommunityPodcast2013-04-12

Maitland, Michelle

19y · Female·severe head injury due to fall during gymnastics on Tumbl Trak, striking uncover…

A 19-year-old female gymnast died from severe head injury after falling from a Tumbl Trak apparatus and striking exposed concrete flooring at a gymnastics club. She…

neurosurgeryemergency medicinesystemcommunicationcannabis
VIChome2021-08-04

Finding into death of NB

1y · Male·Global cerebral ischaemia in an infant with upper airway obstruction

…sing support in foster care, suffered a cardiac arrest on 17 December 2016 that resulted in severe hypoxic brain injury and death. The overnight nurse (Ms Jarina) failed to recognise early signs of tracheostomy obstruct…

respiratory medicineintensive carediagnosticcommunication
VIChome2018-10-03

Finding into death of Yvonne Rose Vizard

72y · Female·Obstruction of the airways of the neck

A 72-year-old woman with moderate-severe expressive and receptive dysphasia following an acute left middle cerebral artery stroke died by hanging three months post-discharge from rehabilitation. Critical deficiencies wer…

neurologyrehabilitation medicinediagnosticsystem
WAhome2007-09-14

Inquest into the Death of Jones Coronial

9y · Male·Head injury (epidural haematoma with cerebral coning following craniotomy)

Dwayne Michael Jones, aged 9, had Trisomy 10, a rare congenital chromosomal disorder causing severe developmental delay and neurological abnormalities. On 11 April 2000, he fell from a computer desk and struck his head. …

general practiceemergency medicinediagnosticdelayparacetamol
VICcommunity2025-09-05

Finding into death of Lisa Nicole Murphy

52y · Female·unascertained - likely combination of underlying natural disease (myocardial inf…

…ffered cardiac arrest and was resuscitated but subsequently developed a massive stroke and diffuse hypoxic brain injury. The medical cause of death remains unascertained, though underlying cardiac disease (myocardial in…

emergency medicineintensive carecommunicationrisperidone
VIChospital2021-09-27

Finding into death of Abigail Louise Cooke-Mitchell

42y · Female·Traumatic right subdural haematoma

…medical assessment occurred when her partner called a home doctor service at 5.14pm reporting a major head injury with swollen face and severe headache, but the service failed to triage appropriately as an emergency requ…

emergency medicineneurosurgerycommunicationdelaymorphine
NSWhospital2022-12-21

Inquest into death of Andrea LESTER

49y · Female·Hypoxic brain injury related to tracheostomy complications in form of airway occ…

Andrea Lester, age 49, suffered a subarachnoid haemorrhage from a PICA aneurysm in March 2018 with delayed diagnosis. Following complex neurosurgery causing Wallenberg syndrome, she required tracheostomy for bulbar dysfu…

neurosurgeryintensive carediagnosticcommunicationtramadol
NSWcommunity2015-11-26

Inquest into the deaths of Donald EVELEIGH, Angela STACKMAN, FW, ML

Quad bike and side-by-side vehicle rollover accidents resulting in drowning, asp…

…e manufacturer age warnings, and lack of formal safety training. Direct causes included drowning from head injury, asphyxiation from crush injuries, and traumatic brain injury. The coroner identified multiple contributin…

occupational and environmental healthpathologysystemalcohol
VIChospital2011-10-26

Finding into death of John Threadgold

55y · Male·Cardiopulmonary arrest, respiratory failure and chronic obstructive airways dise…

Mr John Threadgold, a 55-year-old man with extensive psychiatric history (schizoaffective disorder, substance dependency), chronic obstructive airways disease, and alcohol abuse, died from cardiopulmonary arrest and resp…

psychiatryemergency medicinecommunicationsystemantipsychotic medications
SA2005-09-27

Coroner's Finding: COOK Damian John

24y · Male·consequences of hanging

Damian John Cook, aged 24, died by hanging in his cell at Adelaide Remand Centre after 5 months in custody. His suicidal ideation on the day of death (following difficult phone calls with his ex-partner regarding access …

emergency medicineintensive carediagnosticsystem
NT1994-12-20

Inquest into the death of T. Okano, A. Kabe, T. Linklater and K. Pritchard (Cannonball Run)

Kabe 40, Okano 35, Linklater 22, Pritchard 31y · Male·Kabe and Okano: blunt head injury (head-to-head collision of occupants within ve…

On 24 May 1994, Ferrari F40 driver Akihiro Kabe entered a checkpoint lay-by at excessive speed (>100 kph, possibly 150 kph) following the 87.3 km mark where he mistakenly believed the checkpoint was located. The Ferrari …

emergency medicineforensic medicinedriver errorsystem error
VICaged care2013-02-21

Finding into death of Alexander Ignatius Cody

93y · Male·Intracranial haemorrhage in the setting of over-warfarinisation

A 93-year-old man on warfarin for atrial fibrillation sustained a head strike in a fall at residential aged care. Initial assessment by ambulance was appropriate and he was not transferred. Over subsequent days, neurolog…

geriatric medicineemergency medicinesystemcommunicationwarfarin
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