Coronial
NSW2021-12-22

Inquest into the death of Jack LOH

Male·Unrecognised pulmonary hypertension in a setting of unsafe sleeping conditions

…equate supervision—likely contributed to his death by triggering acute respiratory distress. The educator's CPR accreditation had lapsed, affecting her response. The family day care provider (Kidstart) failed to adequat…

cardiologypathologysystemdelay
NTmental health2025-02-14

Inquest into the death of Pukumani

47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…

…ital observations; (4) incomplete handover missing COPD diagnosis and observation requirements; (5) delayed CPR (7 minutes). Her mental illness overshadowed physical health concerns. Medication change to Aripiprazole, s…

psychiatryemergency medicinediagnosticcommunicationketamine
NSWcommunity2022-09-07

Inquest into the death of Sophia Bolshesolsky

74y · Female·Blunt force injuries sustained when struck by a motor vehicle while crossing Joh…

…the need for traffic management improvements. The main clinical lesson is relevant to emergency responders: CPR and immediate trauma assessment protocols were appropriately implemented by police and ambulance officers a…

TAScommunity2022-12-07

Coroner's Finding: Triffett, Brendan

40y · Male·cardiac arrhythmia caused by atherosclerotic and hypertensive cardiovascular dis…

… cardiac arrhythmia unrelated to his presence in water and unforeseeable from his medical history. Although CPR was administered promptly and competently by trained staff, survival chances were less than 10% even with o…

general practicecardiologyamitriptyline
QLDcommunity2017-11-27

Finlayson, Eric Davis

68y · Male·drowning against a background of cardiomegaly and severe coronary artery calcifi…

…safety roles among undertrained crew. The lookout on the Cay was a 19-year-old trainee without first aid or CPR training. While CPR was eventually performed and was effective, there were delays in accessing emergency eq…

emergency medicineoccupational and environmental healthsystemcommunication
NThome2013-12-18

Inquest into the death of Miss M

15y · Female·cardiac and respiratory arrest following pulmonary aspiration

…piratory arrest due to pulmonary aspiration. She had an Advance Care Directive (ACD) in place specifying no CPR, but resuscitation was initiated by carers and continued by ambulance and hospital staff, who were unaware …

paediatricsemergency medicinesystem
TAShome2023-11-14

Coroner's Finding: de-identified OV

1y · Male·hypoxic brain damage due to laryngeal obstruction from foreign body (metal screw…

…briefly unsupervised at home when he ingested the screw and began choking. Parents and neighbours initiated CPR. Ambulance paramedics arrived within 6 minutes but struggled to visualize and remove the screw due to blood…

paediatricsemergency medicineadrenaline
TASaged care2023-10-10

Coroner's Finding: Rouse, Wayne Victor

68y · Male·Sudden cardiac death due to congestive cardiac failure and chronic obstructive p…

Wayne Victor Rouse, 68, died from sudden cardiac death at a residential aged care facility when CPR was not provided despite his active resuscitation order. Staff incorrectly believed he had a 'do not resusc…

geriatric medicinecardiologycommunicationsystem
QLDcommunity2009-02-10

Lee-Chue, Allan Duncan

45y · Male·acute myocardial infarction due to coronary atherosclerosis

…rrent first aid certification and the vehicle's first aid kit was unavailable. The coroner noted that while CPR was not attempted by police, this would not have altered the outcome given the severity of his coronary dis…

cardiologyemergency medicine
SA2006-11-16

Coroner's Finding: HARKIN Leonard Norman

51y · Male·ischaemic heart disease

…cers, was directed to walk to the medical centre, and collapsed shortly after arrival. Nurse Long initiated CPR appropriately and paramedics continued resuscitation efforts without success. Prior cardiac investigations …

cardiologyemergency medicineproceduraldelaymirtazapine
WAhospital2016-11-16

Inquest into the Death of Shannon Elizabeth MURPHY

33y · Female·Methylamphetamine intoxication leading to agitated delirium and extreme exertion…

…and placed her in recovery position to prevent positional asphyxia. Despite immediate ambulance request and CPR, she died from methylamphetamine and exertion-induced cardiac arrhythmia. The coroner found police response…

emergency medicinetoxicologymethamphetamine
NSW2015-12-03

Inquest into the death of Adam Southwick

37y · Male·methyl amphetamine intoxication while being restrained in a confined space; posi…

… consciousness or cessation of breathing until after arrest had occurred. There was a 3-minute delay before CPR commenced. Early ambulance attendance and placement in recovery position rather than the dock could have pr…

emergency medicineforensic medicinediagnosticcommunicationmethamphetamine
SA2006-05-01

Coroner's Finding: HULSINGA Michael John

27y · Male·left temporal intracerebral haemorrhage due to arteriovenous malformation

Michael John Hulsinga, a 27-year-old male inmate with schizophrenia, died in custody from a spontaneous intracerebral haemorrhage due to arteriovenous malformation. He collapsed suddenly while eating dinner in his cell a…

forensic medicinepsychiatrysystemcommunicationsertraline
VICaged carePodcast2019-08-23

Finding into death of John Reimers

63y · Male·complications of an inverted positional event (asphyxia from airway occlusion)

…h was delayed. Paramedics arrived at 05.42 hours and found him unresponsive and cyanosed, already deceased. CPR was commenced briefly but discontinued when a Not-For-Resuscitation directive was located. The coroner foun…

geriatric medicineemergency medicinediagnosticcommunicationduloxetine
QLD2017-12-15

Martin, Christopher Leslie

65y · Male·Spontaneous lethal arrhythmia on a background of cardiomegaly, myocardial fibros…

Christopher Martin, aged 65, died from cardiac arrest during police restraint following a drink-driving detection. He had significant underlying cardiac disease (coronary artery stenosis, myocardial fibrosis, cardiomegal…

cardiologyforensic medicinedelayalcohol
NTPodcast2025-10-24

Inquest into the death of Ebony Thompson

1y · Female·hypoxic brain injury caused by pressure to the neck from entrapment on a loop-to…

…ence confirmed entrapment risks were not appreciated by centre staff or the NT regulator (QECNT). Immediate CPR would not have saved Ebony given the catastrophic hypoxic injury sustained.

paediatricsemergency medicinesystemcommunication
QLDcommunity2015-11-11

Child A - Non-inquest findings

8y · Female·Anoxia due to fresh water drowning

…cessful escape. Supervision was adequate but momentarily obstructed by a boat. Key clinical lessons: prompt CPR initiation by bystanders and emergency services, early telehealth consultation with paediatric intensive ca…

emergency medicineintensive caresystem
QLDcommunity2015-06-09

Reading, Neville Royston

37y · Male·Cardiac dysrhythmia during restraint against a background of significant alcohol…

Neville Reading, a 37-year-old male, died following cardiac dysrhythmia during restraint on 2 November 2013. He had consumed extremely high quantities of alcohol (blood level 0.26) over 22 hours and became violent, assau…

forensic medicineemergency medicineproceduralcommunicationalcohol
VICcommunity2011-02-21

Finding into death of Constantinos Retsas

60y · Male·Acute myocardial infarction with thrombosis of the left anterior descending coro…

…rior for a chest infection and was prescribed medication. He collapsed in his bedroom and despite immediate CPR and ambulance attendance, could not be revived. The coroner found his management was within normal paramete…

general practice
WA2013

Inquest into the Death of Phillips, Dennis John

51y · Male·Seizure consistent with alcohol withdrawal complicated by naturally occurring ca…

Dennis John Phillips, 51, died from a seizure triggered by alcohol withdrawal while in police custody. He had chronic health issues including diabetes-related amputations requiring daily medication, but police were unawa…

emergency medicinecardiologycommunicationalcohol
134519

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