Coronial

93 results for cognitive disability

QLDcommunity2010-09-07

Simpson-Willson, John Douglas

56y · Male·head injuries inflicted by blunt force trauma

…g without involving his treating psychiatrist or guardian, and grossly under-resourced mental health and disability services. Pattel's threats were known to authorities but without confirmed mental illness diagnosis meet…

psychiatrycorrectional healthdiagnosticcommunication
VIChospital2012-08-24

Finding into death of Cameron Yeates

31y · Male·Acute colonic pseudo-obstruction; death certificate amended to 'unascertained' -…

Cameron Yeates, a 31-year-old man with intellectual disability (IQ 64) and longstanding gastrointestinal issues, died from acute colonic pseudo-obstruction with underl…

gastroenterologygeneral practicecommunicationsystemwarfarin
VIChospital2021-09-02

Finding into death of Robena May Lloyd

58y · Female·Enterococcus faecalis sepsis and acute renal failure

Robena Lloyd, a 58-year-old woman with intellectual disability and schizophrenia, died from enterococcus faecalis sepsis and acute renal failure on 7 August 2009. She …

emergency medicinenephrologydiagnosticcommunicationtrimethoprim
NSWhospital2012-11-01

Michelle Mcilquham Findings

28y · Female·acute streptococcus pneumonia meningitis with left-sided otitis media as anteced…

…ient; no standard investigations were ordered; parental and nursing concerns were not adequately heeded; cognitive bias (premature closure) caused the doctor to anchor to an initial wrong impression; and staff fatigue l…

emergency medicinediagnosticcommunication
WAmental health- 11 April 2014

Inquest into the Death of Amanda Alison GILBERT

47y · Female·bronchopneumonia in context of ischaemic heart disease, chronic renal failure, a…

…ss and brain injury, funding constraints, and inter-agency responsibility gaps between mental health and disability services. While specific clinical care decisions were appropriate, the larger system failed to provide a…

psychiatrygeneral medicinesystemdelaylithium
QLDcommunity2016-09-10

C, a child aged 14 - Non-inquest findings

14y · Female·Hypoxic-ischaemic encephalopathy due to choking on food, as a consequence of foe…

…ff understanding and compliance with individualised eating/swallowing plans for people with intellectual disability; the need for designated health coordinators in residential care; hand-held health records to improve co…

paediatricsemergency medicinesystemcommunication
VICaged care2021-05-24

Finding into death of Julie-Anne Marie Kettle

56y · Female·Bronchopneumonia in the setting of supratherapeutic lithium levels

…edical management by the GP or hospital, which was timely and appropriate. However, systemic failures in disability services management (delayed provision of compression stockings, inadequate falls risk management, unaut…

general practicepsychiatrydiagnosticdelaylithium
VIC2012-11-16

Finding into death of Rebecca Lazarus

25y · Female·Stab wounds to the chest and abdomen

Rebecca Lazarus, a 25-year-old woman with intellectual disability, was fatally stabbed by her partner Travis Cooke who had chronic treatment-resistant paranoid schizophre…

psychiatryemergency medicinecommunicationsystemclozapine
NTcommunity2026-01-23

Inquest into the death of Kumanjayi Johnson

45y · Male·Environmental exposure and dehydration

A 45-year-old Aboriginal man with severe cognitive impairment (6.5-year-old equivalent English comprehension), traumatic brain injury, epilepsy and multipl…

geriatric medicinepsychiatrycommunicationsystem
TAShospital2019-04-18

Coroner's Finding: Davis, Catherine Joy

31y · Female·urosepsis due to acute pyelonephritis

…vent recurrence. Clinical lesson: maintain high suspicion for pyelonephritis in vulnerable patients with cognitive impairment who cannot communicate symptoms clearly.

emergency medicinegeneral medicinediagnosticdelayoral antibiotics via peg tube
VIChospital2014-07-17

Finding into death of Susanne Maree Deeker

64y · Female·Aspiration pneumonia in the setting of Down Syndrome and recent seizures

Ms Susanne Maree Deeker, a 64-year-old woman with Down syndrome, epilepsy, dementia, and gastro-oesophageal reflux disease, died from aspiration pneumonia following recent seizures. She presented to hospital twice in Nov…

emergency medicinegeneral medicine
VIChome2021-10-12

Finding into death of Mr A

51y · Male·Hanging

A 51-year-old man with mild intellectual disability from childhood head injury died by hanging following family violence separation. He perpetrated physical…

general practicepsychiatrycommunicationdiagnosticvenlafaxine
SAhospital2008-01-02

Coroner's Finding: WOOD Jacqueline Moyra

17y · Female·raised intracranial pressure due to hepatic encephalopathy related cerebral oede…

…larly family coercion regarding allegations of sexual abuse she had made, combined with her intellectual disability, epilepsy history, and past trauma. No criticism was directed at healthcare workers; the death could not…

paediatricsintensive carediagnosticparacetamol
VIChospital2025-06-03

Finding into death of DRF

95y · Female·Acute intracranial haemorrhage

DRF, a 95-year-old woman with dementia, hearing impairment, mobility limitations, and mild cognitive impairment, died from acute intracranial haemorrhage following blunt head trauma. She had been living wi…

geriatric medicineneurosurgerycommunicationsystemwarfarin
VIChospital2025-04-17

Finding into death of Graeme William Dimsey

62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…

…blood cultures. The team also failed to diagnose a hip fracture after he fell from his bed. Intellectual disability and delirium complicated assessment, but the coroner found the death preventable because earlier aspirat…

orthopaedic surgeryinfectious diseasesdiagnosticproceduralceftriaxone
VICcommunity2021-11-29

Finding into death of Felicity Ruth Loveday

83y · Female·unascertained

…ting sail from Port Phillip Bay on 11 December 2019 with her son. Ms Loveday had significant medical and cognitive vulnerabilities including severe dementia, stroke history, multiple comorbidities, and 24/7 care depende…

general practicegeriatric medicinesystemdelay
VIC2014-11-24

Finding into death of Diane Maree Wilson

49y · Female·lobar pneumonia in the setting of Down's syndrome and progressive dementia

…entified. Clinical lesson: early recognition of deteriorating oral intake in vulnerable populations with cognitive impairment and multidisciplinary planning for nutritional and hydration support is important, though thi…

palliative caregeneral medicinesodium valproate
NSWcommunity2024-02-20

Inquest into the death of Jasmynd Gibbs

33y · Male·Complications of methylamphetamine use

…in May 2021, less than two months after release. He had complex needs including mental health disorders, cognitive disability, childhood trauma, and substance use issues. Despite a supportive mother initially, Jazzy rel…

correctional healthpsychiatrysystemcommunicationmethamphetamine
NThome2003-07-31

Inquest into the death of Queenie Michaels

11y · Female·pneumonia complicating cytomegalovirus embryopathy

…ueenie Michaels, an 11-year-old Aboriginal girl with cytomegalovirus embryopathy and severe physical and cognitive disabilities, died from pneumonia at home while in government care. She had been fostered by Mr and Mrs …

paediatricsneurologyanti-convulsants
NSWhome2024-03-26

Inquest into the death of MO

6y · Unknown·methadone toxicity

…way doses (6 per week per parent; 12 total weekly doses to the home). The mother had severe intellectual disability which was not adequately considered. The child had previously ingested his parents' medications in 2013.…

addiction medicinepaediatricsdiagnosticcommunicationmethadone

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