Coronial

149 results for blood testing

VIChospital2018-10-11

Finding into death of Sununtha Suttha

57y · Female·Haemopericardium complicating ascending thoracic aortic dissection

…logical symptoms was diagnosed with musculoskeletal back pain and discharged after normal troponin serial testing. She died five days later from haemopericardium due to ascending thoracic aortic dissection. Multiple red…

emergency medicinecardiothoracic surgerydiagnosticcommunicationparacetamol
TAScommunity2024-01-30

Coroner's Finding: Ryan, Robert John

35y · Male·Multiple organ failure—cause not determined to requisite standard

…doramectin toxicity, paroxetine-induced serotonin syndrome, and intentional self-poisoning. Toxicological testing failed to detect farm chemicals in blood samples; autopsy revealed multiorgan failure and oesophageal ulc…

toxicologyintensive carediagnosticdelayparoxetine
TAShome2018-11-05

Coroner's Finding: Unwin, David Paul

55y · Male·probable sepsis in the setting of immunosuppression, a skin wound and chronic di…

…t review (one visit in 9 months versus recommended three-monthly), failure to hospitalise despite critical blood results on 6 January, and poor communication between primary care and specialist. When critical pathology …

nephrologygeneral practicediagnosticdelay
SAhospital2010-10-25

Coroner's Finding: CAMERON Louise Cherise

32y · Female·ischaemic heart disease complicated by upper gastrointestinal haemorrhage

A 32-year-old woman with schizophrenia presented to the emergency department with chest pain radiating to both arms, profuse sweating, and vomiting black material for several days. She also reported black stools. The fir…

emergency medicinecardiologydiagnosticproceduralmorphine
ACT2018-04-11

AN INQUEST INTO THE DEATH OF STEVEN CLAUDE FREEMAN

25y · Male·Aspiration pneumonia secondary to methadone toxicity

… the medical assessment and prescription decisions, though lacking formal assessment tools and urinalysis testing, fell within acceptable clinical practice given the doctor's experience and Steven's reported withdrawal …

addiction medicinegeneral practicediagnosticsystemmethadone
WAhome2004-11-03

Inquest into the Deaths of Jack Craig Anstey and Ashleigh Fiona Mungur

Immersion (Drowning)

… systemic failures: inadequate road signage, insufficient Road Traffic Act provisions for compulsory drug testing in fatal crashes, failure to secure the crash scene, and Main Roads' decision not to fund a permanent bri…

systemdelayamphetamine
QLDhospital2005-08-24

Sabadina, Kathryn Marnie

28y · Female·Anaphylactic reaction to anaesthetic drug (suxamethonium), with underlying coron…

A 28-year-old woman died during routine dental extraction under general anaesthesia at a regional hospital. Despite competent initial airway management, she developed severe respiratory distress immediately after inducti…

anaesthesiadentistrydiagnosticproceduralpropofol
WAhospital2008-02

Inquest into the Death of Evans

45y · Female·Extensive retroperitoneal haemorrhage following bone marrow biopsy procedure wit…

…risk), and monitoring. Recommendations addressed imaging-guided biopsy, expedited notification of abnormal blood results, and complete recording of observations.

haematologygeneral medicinewarfarin
WAmental health

Inquest into the Death of Vincent Tavita Tolai SCHWENKE

24y · Male·complications of ligature compression of the neck (hanging)

Vincent Schwenke, a 24-year-old male of Maori descent, developed acute psychotic symptoms after ceasing cannabis use and was admitted to a secure mental health unit as an involuntary patient. Despite initial improvement …

psychiatryneurologyescitalopram
QLDaged care2026-01-15

Inquest into the death of Steven Thelander

29y · Male·Ketoacidosis as a consequence of diabetes mellitus (Type 1)

…port workers who lacked understanding of diabetes pathophysiology; failure to escalate non-compliance with blood sugar monitoring despite recorded high readings (BSLs >20) and a low reading of 2; inadequate diabetes man…

general practiceendocrinologydiagnosticcommunicationinsulin
NSWmental health2011-09-02

Ang 2011 09 21 13 31 50 906

29y · Male·acute bronchopneumonia complicated by multi-drug toxicity

Nicholas Ang, aged 29, with schizoaffective disorder, died from acute bronchopneumonia complicated by multi-drug toxicity while in a psychiatric unit. Admitted 12 August 2005, he was on clozapine, valproic acid, and clon…

psychiatrygeneral medicinemedicationcommunicationclozapine
SAcommunity2015-04-24

Coroner's Finding: BYRNE Philip John and WEAVER Jacqueline

Philip Byrne: pulmonary thromboembolism due to right calf deep vein thrombosis; …

…ey lessons: DVT cannot be reliably excluded clinically; calf pain without clear trauma warrants objective testing; recent long-haul travel is a critical risk factor; Wells Score System has limitations in community pract…

general practicephysiotherapydiagnosticcommunicationwarfarin
NTmental health2009-04-09

Inquest into the death of Paul Guarini

38y · Male·self-inflicted hanging

Paul James Guarini, a 38-year-old university student with a history of relationship difficulties, suicide attempts, and depression, died by hanging in Cowdy ward at Royal Darwin Hospital on 14 September 2007, within 10 m…

psychiatryemergency medicinediagnosticsystemparoxetine
SAhome2012-02-20

Coroner's Finding: WYATT David James and WYATT Jakob James

24y · Male·Blood loss due to multiple stab wounds to chest and multiple incised wounds of n…

… a mental impairment finding and was subject to strict conditions including mental health treatment, drug testing, and anger management. Critical failures included: minimal compliance with urinalysis testing (7 of ~90 e…

psychiatrycorrectional healthsystemcommunicationmethamphetamine
NSWhospital2021-10-12

Inquest into the death of Bruce HODGES

78y · Male·cardiorespiratory failure due to complications of tracheal stenosis

…irway narrowing warranted closer monitoring and potentially transfer to higher-level care; (4) An arterial blood gas test should have been performed to assess carbon dioxide retention; (5) Specialist review by respirato…

emergency medicineENT surgerydiagnosticsystemnebulised saline
VIChospital2026-02-11

Finding into death of Michael Robert Burns

58y · Male·Pulmonary thromboembolism complicating right calf deep venous thrombosis

…e Wells score was applied. If it was applied (with a score of zero), clinical guidelines required D-dimer testing; this test would likely have been positive and led to further imaging, potentially identifying the PE bef…

cardiologyemergency medicinediagnosticcommunicationbisoprolol
QLDhospital2015-11-03

Steer, Summer Alice

4y · Female·Haemorrhage due to aorto-oesophageal fistula caused by ingestion of a button bat…

…pain and likely black stools (melaena), treating presumptively for Giardia without basic questioning about blood in stools. The private hospital doctor discharged the child within 15 minutes of arrival despite multiple …

general practiceemergency medicinediagnosticcommunicationmetronidazole/flagyl
QLDhospital2024-12-16

Inquest into the death of Shane Anthony May

61y · Male·Multiorgan failure, due to, or as a consequence of metastatic lung cancer (suspi…

Shane Anthony May, a 61-year-old prisoner, died of multiorgan failure secondary to metastatic lung cancer after 44 days in custody. He presented with COVID-19 symptoms on reception, then developed progressive respiratory…

emergency medicinerespiratory medicineamlodipine
QLDhospital2013-04-16

Hornby, Geoffrey John

58y · Male·Respiratory failure due to or as a consequence of Chronic Obstructive Pulmonary …

Geoffrey Hornby, a 58-year-old prisoner with significant COPD, ischemic heart disease, and multiple comorbidities, died from respiratory failure secondary to COPD. He was admitted to hospital with COPD exacerbation and d…

respiratory medicineemergency medicinecommunicationdelaysalbutamol
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…

…ation. A psychiatrist's July 2010 recommendation for liver assessment was received but resulted in delayed blood tests that were never completed before her transfer between prisons. On 13 September, she presented with n…

general practicehepatologycommunicationsystem
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