Coronial

123 results for x-ray imaging

TAShospital2018-03-14

Coroner's Finding: Little, Neita Jean

79y · Female·aspiration pneumonia caused by aspiration of emesis secondary to small bowel obs…

… warrants urgent investigation; (2) oxygen desaturation (3am) was a red flag requiring medical review and imaging which was not obtained; (3) Dr J.'s assessment at 9.45am, concluding discharge fitness despite seven vomi…

gynaecologyanaesthesiadiagnosticcommunicationrivaroxaban
SAhospital2022-12-22

Coroner's Finding: Hammond, Peter Joseph

66y · Male·inanition and probable respiratory tract infection complicating Alzheimer's deme…

…l symptoms. In April 2020 he developed pneumonia; in June he suffered falls with suspected hip injury but imaging was not pursued due to resistance. By late June he was febrile, hypoxic and had reduced oral intake. A pa…

geriatric medicinepsychiatry
NT2026-03-19

Inquest into the death of Bradley Murdoch

66y · Male·metastatic adenocarcinoma (palliated) from an unidentified primary tumour

…mber 2024 with non-specific symptoms including neck swelling, cough and shortness of breath. Initial chest X-ray was unremarkable but CT imaging identified mediastinal lymphadenopathy prompting urgent transfer to hospit…

oncologypalliative carecarboplatin
VIChospital2020-07-02

Finding into death of Craig Vincent Douthie

52y · Male·C2, C3, C4 spinal injury sustained from a fall secondary to seizures

A 52-year-old man with cerebral palsy, epilepsy, and intellectual disability living in disability accommodation fell in the bathroom after a seizure and sustained cervical spine fractures (C2-C3-C4). He was admitted to h…

emergency medicineneurosurgerydelaycommunicationlevetiracetam
ACThospital2025-04-09

Inquest Into The Death Of Peter Hanisch

69y · Male·thoracic aortic aneurysm with dissection

…nicians to maintain high clinical suspicion for aortic dissection when symptoms are consistent, even when imaging reports appear to exclude it. The case highlights gaps in quality assurance systems for imaging services.

radiologyemergency medicinediagnosticsystem
SAaged care2017-05-30

Coroner's Finding: ABBOTT Raymond

70y · Male·chronic obstructive lung disease with emphysema on a background of advanced vasc…

…d to have a large left spontaneous pneumothorax requiring chest drain insertion. Despite drain placement, imaging on 23 March showed the pneumothorax had increased with persistent subcutaneous emphysema. His condition d…

respiratory medicinegeneral medicinemidazolam
VIChospitalNew2026-08-21

Finding into death of Susanne Keating

64y · Female·Presumed massive pulmonary embolus

Mrs Keating, aged 64, presented to University Hospital Geelong ED with a two-day history of shortness of breath and cough, with known history of pulmonary embolism. Attending physicians appropriately considered PE as dif…

emergency medicinegeneral practicedelaysystem
NSWhospital2018-06-06

Inquest into the death of Dr Malay Rana

27y · Male·Loss of airway control and blockage due to aspiration from complications of a sm…

…ration despite objective warning signs including tachycardia (130), fever (39.4°C), elevated lactate, and imaging changes; (3) premature removal of nasogastric tube (NGT) without sufficient safeguards or written senior …

respiratory medicinegeneral surgerycommunicationdiagnosticfentanyl
VIChospital2018-11-19

Finding into death of Robert Humphreys

71y · Male·Aspiration in setting of paralytic ileus in patient in convalescent phase of abd…

…ormal bowel movements), the surgeon Dr C. did not reinstate bowel rest, nasogastric tube, or radiological imaging. He declined a medical registrar review when contacted on day 8 evening despite family concerns about det…

vascular surgeryintensive carediagnosticdelayatropine
SAhospital2001-10-19

Coroner's Finding: McCARTHY Nancy Clare

67y · Female·bronchopneumonia complicating disseminated pulmonary large cell carcinoma with r…

…cutely with confusion, agitation, and respiratory distress, necessitating Mental Health Act detention. CT imaging revealed advanced disseminated lung cancer with metastases to liver, adrenal glands, and brain. She devel…

general practiceemergency medicinediagnostic
NThospital2015-02-19

Inquest into the death of Victor Campbell

63y · Male·cancer in the left lung metastatic to the heart, right lung, liver, pancreas and…

…nal Centre on 10 April 2013. He was assessed by medical staff and seen by a doctor promptly. By May 2013, imaging revealed an irregular nodule that was later found to be metastatic adenocarcinoma of the lung with widesp…

oncologypalliative caredexamethasone
VIChospital2022-03-09

Finding into death of Daniel McQuilken

68y · Male·Lung cancer

Daniel McQuilken, a 68-year-old man in immigration detention, died from metastatic lung cancer. His lung cancer diagnosis was made while detained, likely related to his significant smoking history and prior asbestos and …

oncologyrespiratory medicinechemotherapy agents
SAhospital2022-08-15

Coroner's Finding: Larchin, John

87y · Male·infective exacerbation of chronic obstructive lung disease

…Orders were appropriately made to enable medical treatment including oxygen therapy and monitoring. Chest imaging subsequently revealed emphysema and signs of infection. He deteriorated despite antibiotics and non-invas…

orthopaedic surgerypsychiatryhaloperidol
VIChospital2025-12-08

Finding into death of Graeme William Kenny

61y · Male·Right lower lobe pneumonia

…nfection progression in this population despite apparently stable vitals; consider earlier escalation and imaging (chest X-ray) when productive cough persists despite antibiotics.

emergency medicinegeneral practicediagnosticdelayibuprofen
SAhome2020-07-16

Coroner's Finding: KEIPERT Mathew James

44y · Male·Ischaemic heart disease due to coronary atherosclerosis

…and dyspnoea on exertion, concerning for possible cardiac pathology. Despite investigation including chest X-ray, abdominal ultrasound, and echocardiogram (all reportedly normal), the underlying coronary artery disease …

cardiologygeneral practicediagnosticdelaybuprenorphine
TAShospital2020-08-12

Coroner's Finding: Maynard, Grant Godfrey

60y · Male·multi-organ failure due to injuries sustained in motor vehicle accident, specifi…

…, renal failure, diabetes) presented to ED following a motor vehicle accident at low speed. Despite chest imaging showing pleural effusion and the patient having rib pain, fractured ribs were not diagnosed. Subsequently…

emergency medicinegeneral medicinediagnosticdelaydoxycycline
SAhospital2018-03-29

Coroner's Finding: BUTSON Graham Joseph

81y · Male·aspiration of gastric contents complicating disseminated moderately differentiat…

…astases. He presented with confusion, agitation and atrial fibrillation; a lung mass was suspected but CT imaging could not be completed due to his acute delirium. He was detained under mental health legislation for saf…

orthopaedic surgerygeneral medicinesystemwarfarin
QLDhospitalPodcast2011-10-07

Saunders, Ryan Charles

2y · Male·Group A Streptococcal toxic shock syndrome which probably originated in the thro…

Ryan Saunders, a 2-year-old boy, died from Group A Streptococcal toxic shock syndrome after a 72-hour presentation with fever, pain, and systemic illness. Initial GP care was appropriate given the presentation and diagno…

paediatricsemergency medicinediagnosticcommunicationparacetamol
WAhospital2020-09-04

Inquest into the Death of Malakai Matiu Ward PARAONE

<1y · Male·Complications in association with fulminant sepsis in an infant (Streptococcus p…

… God Midland Hospital on 23 August, a pulled elbow was suspected; when the child appeared to improve after X-ray manipulation, infection was excluded. At Princess Margaret Hospital ED the same day, despite fever, tachyc…

emergency medicineintensive carediagnosticcommunicationparacetamol
WAhome2007-09-14

Inquest into the Death of Jones Coronial

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

…was attempted but Dwayne died from cerebral coning. The coroner found the critical failure was delayed CT imaging. Early neurological imaging on 11 April would likely have changed the outcome. The case highlights the ch…

general practiceemergency medicinediagnosticdelayparacetamol

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