Coronial
WAcommunity2025-08-22

Inquest into the Death of David Kalunda FLYNN

2y · Male·Cardiorespiratory arrest in a young child with opioid (morphine) toxicity

…m opioid overdose. Experts agreed that if David had been properly monitored at the clinic, his dangerous drowsiness would have been detected and an antidote could have been given, likely saving his life. The case highlig…

general practicegeneral surgerymedicationproceduralmorphine
VIChospital2020-03-18

Finding into death of Sommer Bethany Warren

18y · Female·Generalised tonic-clonic seizure and cardiac arrest arising from severe hyperten…

An 18-year-old pregnant woman presented in labour at 41 weeks and 2 days gestation. From 23 September onwards, she experienced intermittent headaches, epigastric pain, proteinuria and peripheral oedema. At 1755 hours on …

obstetricsanaesthesiamedicationdiagnosticropivacaine
QLDhospital2016-03-18

McGuane, Shirley Fay - Non-inquest findings

84y · Female·Myocardial infarction

…nfarction. Significant anaemia (Hb 72, down from 127) and signs of deterioration (oliguria, tachycardia, drowsiness) were not adequately escalated or investigated. No MERT call was made despite meeting criteria. Standard…

surgerycardiologydiagnosticcommunicationwarfarin
WA2001-11-19

Inquest into the Death of Adam Timothy Garner

18y · Male·Ligature Compression of Neck (Hanging)

Adam Timothy Garner, aged 18½, died by hanging in his prison cell at Canning Vale Prison Complex on 6 January 2000, approximately 24 hours after admission. He was on remand for a serious violent offence and was experienc…

correctional healthpsychiatrysystemcommunicationprescription medication for alcohol and drug withdrawal
VICaged care2023-02-23

Finding into death of H D

87y · Female·Complications following a medication administration error in a woman with multip…

…al practitioner who reviewed the chart, or pharmacy staff before administration. The patient's resulting drowsiness and decline contributed to her death. Multiple system failures occurred: rushed transition timing near p…

geriatric medicinegeneral practicemedicationsystemrisedronate
VIChospital2019-07-30

Finding into death of Allison Judith Allan

43y · Female·Hypoxic ischaemic brain injury resulting from alcohol and sodium valproate toxic…

43-year-old woman with epilepsy and depression died from hypoxic ischaemic brain injury after ingesting 15g sodium valproate and 750ml vodka. Critical failures occurred across multiple settings: VPIC provided incomplete …

emergency medicineintensive carediagnosticcommunicationsodium valproate
ACTcommunity2021-11-15

Inquest into the death of Blake Andrew Corney

4y · Male·fatal head injury sustained as a passenger in a motor vehicle collision

Blake Corney, 4 years old, died from catastrophic head injuries when a heavy truck driven by Mr Akis Livas collided with his stationary family vehicle at an intersection. The driver had undiagnosed or unaddressed suspect…

systemcommunication
QLDhospital2011-06-29

Heidrich, Bela

0y · Female·Mechanical asphyxia due to or as a consequence of overlaying while bed-sharing d…

Bela Heidrich, a newborn, died from mechanical asphyxia due to overlaying while bed-sharing with her mother during breastfeeding in hospital. The mother, Zelia, was exhausted after labour and fell asleep while breastfeed…

midwiferyobstetricscommunicationsupervisionpethidine
SAcommunity2011-06-22

Coroner's Finding: TATCHELL Melissa Jay

28y · Female·bronchopneumonia complicating oxycodone toxicity

…led to review or challenge the oxycontin dosage despite the patient exhibiting severe overdose symptoms (drowsiness, falling asleep mid-sentence) during admission. Staff advised the patient to break slow-release tablets …

general practiceemergency medicinemedicationdiagnosticoxycodone
NSWhospital2021-11-09

Inquest into the death of Caitlin CRUZ

3y · Female·complications of Influenza B viral infection

Three-year-old Caitlin Cruz presented to a medical centre unwell and collapsed, requiring resuscitation. She was transferred by ambulance to Children's Hospital at Westmead but critical information about her collapse and…

emergency medicinepaediatricscommunicationdiagnosticmidazolam
VIChospital2021-09-27

Finding into death of Abigail Louise Cooke-Mitchell

42y · Female·Traumatic right subdural haematoma

A 42-year-old woman died from a traumatic right subdural haematoma sustained on 22 January 2015. She was found unresponsive at home with severe head and facial injuries after falls. Critical delays in medical assessment …

emergency medicineneurosurgerycommunicationdelaymorphine
WAhospital2012-10-05

Inquest into the Death of Rasmussen vaughn

15y · Male·Cerebral ischaemia in a young man with a blocked ventricular peritoneal shunt an…

…esented to two hospitals four times with symptoms consistent with VP shunt blockage (headache, vomiting, drowsiness, neck hyperextension, seizures). Critical clinical opportunities to diagnose the intermittently blocked …

general practicegeneral medicinediagnosticcommunicationlamotrigine
VIChome2025-07-28

Finding into death of Heather Ida Simone Calgaret

30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…

…ion on 22 November 2021, she experienced symptoms consistent with opioid intoxication (nausea, vomiting, drowsiness). While asleep that night, she likely experienced respiratory depression from the combination of bupreno…

general practiceaddiction medicinemedicationdiagnosticbuprenorphine
QLDhospital2012-06-22

Paton, Daniel William

45y · Male·Hypoxic-ischaemic encephalopathy due to prolonged hypoxia

A 45-year-old man died from hypoxic-ischaemic encephalopathy following cardiopulmonary arrest 11 hours after elective wrist plate removal surgery. Multiple contributing factors were identified: undisclosed obstructive sl…

anaesthesiapain medicinediagnosticmedicationmorphine

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