Coronial

115 results for ambulance transport

VIChospital2011-06-16

Finding into death of Owen Appleby

0y · Male·Hypovolemic shock, metabolic acidosis and coagulopathy in association with subga…

…zed complication of vacuum extraction. The coroner found that early contact with NETS (Newborn Emergency Transport Service) at or after 7:00am was not made, despite clinical deterioration suggesting differential diagnos…

obstetricsneonatologydiagnosticdelayprostin gel
VIChomePodcast2018-11-09

Finding into death of Le Hue Huynh

46y · Female·hypoxic ischaemic encephalopathy complicating cardiorespiratory arrest in the se…

…d 000 at 6:42pm during unprecedented demand (2,332 calls in 12 hours, 397 in 30 minutes), and her family transported her to hospital where she was found in cardiac arrest. Prolonged resuscitation caused hypoxic brain in…

emergency medicineintensive caresystemdelaysalbutamol
VIChospital2021-09-27

Finding into death of Abigail Louise Cooke-Mitchell

42y · Female·Traumatic right subdural haematoma

…ollen face and severe headache, but the service failed to triage appropriately as an emergency requiring ambulance attendance. Instead, a doctor was assigned 3 hours later. The ambulance was only called at 9.36pm after …

emergency medicineneurosurgerycommunicationdelaymorphine
NSWhospital2011-08-15

Coroner's Finding: Jacob Leonel Belim

8y · Male·Septic shock consequent on burst appendix with peritonitis

Jacob Belim, aged 8, presented to a GP with appendicitis on 24 March 2009 but the diagnosis was missed. The next day, his treating doctor correctly diagnosed ruptured appendix and referred him urgently to hospital. At Li…

emergency medicinegeneral practicediagnosticcommunicationampicillin
NSWcommunity2025-03-06

Inquest into the death of Fiona Turnbull

59y · Female·multiple injuries from fall from height

…aking responsibility rests with clinicians, not families; (3) Information sharing between NSW Police and Ambulance NSW about mental health history was inadequate—police possessed records of Fiona's psychiatric history b…

psychiatryemergency medicinedelaycommunicationclozapine
TAShospital2018-05-30

Coroner's Finding: Forward, Trudi Maree

53y · Female·sepsis and multiple organ failure attributable to infarction/necrosis of small b…

A 53-year-old woman with Type II diabetes, obesity, and Korsakoff dementia presented with acute severe abdominal pain from superior mesenteric artery (SMA) thrombosis at 3:00 AM on 19 August. Despite elevated lactate, me…

emergency medicinegeneral surgerydiagnosticdelay
WA2020-08-18

Inquest into the Death of Hayden Paul STACEY

22y · Male·gunshot injury to the chest

Hayden Paul Stacey, 22, died from a gunshot wound to the chest inflicted by police constable Lucinda Boon during a mental health crisis incident on 27 May 2018 at Peel Health Campus, Western Australia. Stacey had called …

emergency medicineparamedicinesystemcannabis
VIChome2019-08-01

Finding into death of Caleb Harley Pearson

17y · Male·Diabetic ketoacidosis

… his presentation to anxiety and upper respiratory infection. They did not take a blood glucose level or transport him to hospital. He died from diabetic ketoacidosis (DKA) six hours later. The coroner found his death w…

emergency medicinepaediatricsdiagnosticcommunicationpholcodine
SAhospital2026-05-28

Coroner's Finding: Sargeant, Gary Dale

36y · Male·Drowning

Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical ps…

general medicinepsychiatrydiagnosticprocedural
ACTcommunity2018-02-27

AN INQUEST INTO THE DEATH OFELFRIEDE ADELE TREMETHICK

85y · Female·acute exacerbation of congestive heart failure, following injuries suffered in a…

Ms Tremethick, an 85-year-old with congestive heart failure, fell at home and suffered a lacerated forearm. Paramedics attended and initially administered methoxyflurane for pain relief. She developed fulminant pulmonary…

emergency medicineparamedicineproceduralcommunicationmethoxyflurane
NThospital2005-08-31

Inquest into the death of Marcellus Tipiloura

26y · Male·Suicidal cut throat

…hroat that severed his trachea. Paramedics administered Midazolam to manage his violent agitation before transport to hospital, where resuscitation efforts failed. The coroner found no fault with police, paramedic, or h…

emergency medicineforensic medicinemidazolam
QLDhospital2008-10-14

Mathers, John William

26y · Male·Air embolism due to ruptured spleen (surgery) due to motorcycle accident

…sion pump during surgery, causing cardiac arrest. Clinical lessons: (1) Severe trauma patients should be transported directly to equipped trauma centres, not nearest hospitals; (2) Staff used the Level 1 infuser without…

emergency medicinetrauma surgerycommunicationsystem
WAhospital2016-12-16

Inquest into the Death of Ms DHU

22y · Female·staphylococcal septicaemia and pneumonia complicating osteomyelitis of a right 1…

…e was feigning symptoms and treated her unprofessionally and inhumanely during her final hours, delaying ambulance transfer. Multiple systemic failures in medical assessment, police supervision, lock-up procedures, and …

emergency medicineinfectious diseasesdiagnosticcommunicationamphetamine
VICcommunity2014-03-03

Finding into death of Shannon McCormack

22y · Male·Cranial fracture, epidural haemorrhage, marked cerebral oedema and diffuse axona…

…rcation. Despite sustaining a significant head wound with loss of consciousness at the scene, he was not transported to hospital immediately. Security staff provided basic first aid, and he was taken home by friends. He…

emergency medicineneurosurgerydelay
QLDcommunity2020-08-27

Master Carr and Jaylen

17y · Male·multiple injuries due to motor vehicle collision

Two juvenile males, aged 17 and 16, died in a high-speed motor vehicle crash on the Gore Highway near Wyaga Creek on 21 April 2018. The vehicle, a stolen Holden Commodore, was traveling at approximately 170-175 km/h when…

forensic medicineproceduralsystemmethamphetamine
WAhome

Inquest into the death of Nicole Emily BICKNELL

18y · Female·Acute Alcohol Toxicity with Early Pneumonia and Aspiration

… recovery position with monitoring and a bucket, but was not recognized as a medical emergency requiring ambulance transport. She vomited and aspirated gastric contents, developing early pneumonia. Approximately 2-3 hou…

toxicologyemergency medicinedelaysystemalcohol
VIC2018-03-09

Finding into death of Damien Nobile

37y · Male·Acute epiglottitis

…nned. Within an hour, the patient deteriorated significantly with respiratory distress. Despite eventual ambulance transport and treatment, he died from acute epiglottitis. Key clinical lessons: vital signs should alway…

emergency medicinegeneral practicediagnosticcommunicationcelecoxib
QLDcommunityPodcast2019-06-12

Brown, Holly Winta

17y · Female·Arrhythmia due to myocardial scarring secondary to past myocarditis, possibly fr…

Holly Brown, 17, died of fatal cardiac arrhythmia from undiagnosed heart scarring likely due to childhood rheumatic fever. She collapsed at a regional mass gathering event (2000+ attendees) in remote Laura, Queensland. C…

emergency medicinegeneral practicesystemcommunicationadrenaline
NSWhome2024-12-09

Inquest into the death of Jet Gallagher

19y · Male·In keeping with hanging

…old male with depression and anxiety died by hanging at his home on 5 March 2021, hours after police and ambulance attended him in the early morning of 4 March following his brother's emergency call. Jet had consumed Va…

paramedicinepsychiatrycommunicationdiagnosticdiazepam
VIChospital2018-12-14

Finding into death of Yucel Arslan

40y · Male·Methamphetamine toxicity

… him swallowing the substance, he ingested it anyway. Despite paramedics attending and offering hospital transport, the man refused treatment and did not disclose what he had ingested. He presented to hospital approxima…

emergency medicinetoxicologycommunicationsystemmethamphetamine

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