Coronial
VICmental health2015-12-07

Finding into death of Jeffrey John Hartwig

43y · Male·Pneumonia

…pines, and antipsychotics. Clinical staff noted signs of possible infection on 10 December (fever, cough, headache) and chest infection concerns on 11 December, but formal vital observations ceased after 10 December. He …

psychiatryintensive caremonitoringcommunicationmethadone
TAShospital2017-11-01

Coroner's Finding: French, Steven John

57y · Male·large volume ischaemic infarct (stroke)

…phen John French, a 57-year-old with prior stroke (2002) and myocardial infarction (2009), presented with headache, visual disturbance and gait difficulty in May 2013. Imaging at Launceston General Hospital on 30 May dem…

neurologyradiologydiagnosticcommunicationenoxaparin
NSWhospital2014-05-09

Inquest into the death of Brendan BURNS

24y · Male·acute hydrocephalus due to undiagnosed colloid cyst of the third ventricle of th…

…sed by an undiagnosed colloid cyst of the third ventricle. He presented with progressive severe occipital headaches, dizziness, blurred vision, nausea and vomiting over one week. On 25 January 2009, Dr H. at Hay Hospital…

emergency medicineneurosurgerydiagnosticcommunicationmorphine
SAhospital2008-08-15

Coroner's Finding: EDWARDS Natasha Anne

31y · Female·right cerebellar cerebrovascular accident (cerebellar infarction with obstructiv…

31-year-old woman presented with acute onset headache, dizziness, vomiting, facial numbness and speech difficulties. Initial CT brain showed equivocal left tem…

neurologygeneral medicinediagnosticdelaymetoclopramide
NT2012-01-04

Inquest into the death of Barnabas Naroldol

33y · Male·Longstanding atheromatous coronary artery disease with severe stenosis and cardi…

…artery disease with cardiac hypertrophy. On presentation to the prison clinic with non-specific symptoms (headache, throat pain, arm and chest pain), chest pain was not clearly documented—he denied it when directly asked…

general practiceemergency medicinecommunicationsystemparacetamol
NSWhospital2011-12-21

Coroner's Finding: Gabrielle Coventry

14y · Female·Neisseria meningitidis infection (meningococcal septicaemia)

…ar-old girl presented to Gosford Hospital Emergency Department on 4 December 2007 with high fever (40°C), headache, vomiting, myalgia, and haemodynamic instability (hypotension, tachycardia, tachypnoea)—all signs of seri…

emergency medicinepaediatricsdiagnosticmedicationceftriaxone
TAShospital2018-10-17

Coroner's Finding: Jones, Tristan Adam

40y · Male·Subarachnoid haemorrhage due to ruptured right middle cerebral artery aneurysm

A 40-year-old man presented to the ED with sudden-onset severe headache, slurred speech, and vomiting. He was appropriately triaged and quickly diagnosed with subarachnoid haemo…

emergency medicineneurosurgerysystemcommunicationparacetamol
SAhospital2009-07-30

Coroner's Finding: BRUNT Sidney

65y · Male·acute right subdural haematoma

…n but failed to implement any INR monitoring despite understanding this requirement. On presentation with headache and leg pain suggesting intracranial bleeding on 11 November 2005, the examining physician was unaware of…

general practiceemergency medicinemedicationcommunicationwarfarin
SAhospital2006-05-12

Coroner's Finding: MARTIN Kirsten Lee

24y · Female·multi organ failure due to meningococcal septicaemia

24-year-old woman presented to ED with fever (40.1°C), headache, myalgia and mild photophobia. RMO Dr R., relatively inexperienced (5 weeks in Australia), examined her t…

emergency medicineinfectious diseasesdiagnosticcommunication
WAprison- 31 January 2014

Inquest into the Death of Amy TINKER

33y · Female·multiple organ failure complicating sepsis in a woman with cirrhosis of the live…

…completed before her transfer between prisons. On 13 September, she presented with non-specific symptoms (headache, dizziness) and was assessed for dehydration only. She deteriorated rapidly with sepsis and died two days…

general practicehepatologycommunicationsystem
SAhospital2013-04-08

Coroner's Finding: MAY Terrill Anthony

69y · Male·subarachnoid haemorrhage with contributing cardiomegaly

A 69-year-old man with hypertension presented with sudden onset severe headache, photophobia, nausea and neck stiffness—classic features of subarachnoid haemorrhage. A CT angiogram iden…

emergency medicineneurosurgerydiagnosticcommunicationperindopril
WAprison2024-02-21

Inquest into the Death of Iain Campbell BUCHANAN

65y · Male·complications, including pneumonia, of traumatic brain injury

A 65-year-old male prisoner died from complications of severe traumatic brain injury sustained when punched by another prisoner at Hakea Prison. He fell backwards, striking his head, and was assessed at the prison medica…

neurosurgeryemergency medicinedelaysystem
QLDcommunity2020-09-07

C - Non-inquest findings

6y · Male·Sepsis due to melioidosis

…resentations to a remote hospital over five days (5–10 January 2017) with fever, vomiting, diarrhoea, and headache. Initial diagnosis of viral gastroenteritis was reasonable given the rarity of melioidosis in children an…

paediatricsinfectious diseasesdiagnosticcommunicationparacetamol
SAhospital2006-09-25

Coroner's Finding: McCARTHY Elly Sarahnia

13y · Female·cerebral oedema and infarction secondary to extensive subdural empyema

…ar-old girl, died from cerebral oedema and infarction secondary to subdural empyema. She developed fever, headache and neurological symptoms on 24 January 2004 and was initially seen at a GP and Noarlunga Health Service.…

paediatricsemergency medicinediagnosticcommunicationtrimethoprim
TAShospital2017-05-17

Coroner's Finding: Woulleman-Jarvis, Anne Maree 2017 TASCD 188

62y · Female·subacute subdural haematoma due to a closed head injury sustained in a fall from…

…ral practitioner accepted this normal report. Five days later, the patient presented to ED with worsening headaches unresponsive to opioids and nausea. Despite her anticoagulated status, recent head trauma, and concernin…

general practiceemergency medicinediagnosticcommunicationwarfarin
NSWcommunity2008-01-24

Coroner's Finding: Vanessa Ann Anderson

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

Vanessa Anderson, 16, suffered a depressed skull fracture from a golf ball strike and was admitted to Royal North Shore Hospital. She died from respiratory arrest due to opioid-induced respiratory depression, which was e…

neurosurgeryanaesthesiamedicationcommunicationoxycodone
NSWhospital2012-11-01

Michelle Mcilquham Findings

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

…ection. She presented to Bankstown Hospital Emergency Department with a first-time seizure, fever, severe headache and ear pain. Despite multiple clear danger signs and repeated nursing escalations of concern, the junior…

emergency medicinediagnosticcommunication
QLDhospital2008-09-12

Neville, Elise Susannah

10y · Female·Head injuries due to fall from a bunk bed

Elise Neville, aged 10, fell from a non-compliant bunk bed and sustained a head injury. At her first ED presentation to Caloundra Hospital at 3:25am, Dr D.—a junior house officer 19 hours into a 24-hour shift—failed to p…

emergency medicineneurosurgerydiagnosticcommunicationmannitol
QLDhospital2014-12-08

Gulliver, Graeme Barry; Harrison, Joanne Lee; Morten, Aileen Margaret

21y · Male·Sepsis caused by Leptospirosis (Graeme Gulliver); Group A streptococcal meningit…

…er and died. The second patient (28-year-old with Group A streptococcal meningitis) presented with fever, headache, and neck stiffness on 9 January but was not reviewed by a doctor on admission and only comprehensively a…

emergency medicineinfectious diseasesdiagnosticsystem
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…

…12-16 November, he presented to two hospitals four times with symptoms consistent with VP shunt blockage (headache, vomiting, drowsiness, neck hyperextension, seizures). Critical clinical opportunities to diagnose the in…

general practicegeneral medicinediagnosticcommunicationlamotrigine

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