Coronial

332 results for emergency patient transfer

NSWhospital2021-11-09

Inquest into the death of Caitlin CRUZ

3y · Female·complications of Influenza B viral infection

…ear-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 abnorm…

emergency medicinepaediatricscommunicationdiagnosticmidazolam
VIChospital2015-04-02

Finding into death of Joseph Mallia

53y · Male·metastatic pancreatic cancer

…n the need for MRI and explained cancer risks, Mr Mallia signed a treatment refusal citing concerns about transfer to Port Phillip Prison. The coroner found this refusal appeared linked to security fears rather than medi…

general practiceradiologydelaysystem
WAhospital2016-05-18

Inquest into the Death of Janice May SAULYS

69y · Female·multi-organ failure due to sepsis of unknown origin

… dehydration, and early renal failure. Despite appropriate investigations ordered by her GP and attempted transfer to a tertiary facility, she deteriorated and died 7 days later from septic shock. The coroner found care …

emergency medicinegeneral practicesystemdelay
WAhospital2009-09-11

Inquest into the Death of Gordon

1y · Female·pneumonia (staphylococcal pneumonia with bilateral bacterial pneumonia)

…re IV fluids were started. The IV line subsequently tissued and was never successfully restarted. She was transferred by RFDS aircraft but deteriorated en route and died shortly after arrival at Port Hedland Hospital. Th…

general practiceemergency medicinediagnosticdelayparacetamol
SAhospital2004-04-30

Coroner's Finding: YOUNG Iris Patricia

60y · Female·haemorrhagic shock and respiratory failure due to right-sided haemothorax compli…

…ffusion on 30 November 2000. Complications included undetected bleeding into the pleural cavity. When the patient deteriorated three hours post-procedure, clinicians made a provisional diagnosis of pulmonary embolism (c…

oncologyrespiratory medicinediagnosticcommunicationheparin
VICcommunity2021-03-10

Finding into death of Jack David watson

26y · Male·Plastic bag asphyxia in the setting of a vitiated atmosphere with inert gases

…asis despite ongoing suicide risk and concerning statements to his father about manipulating doctors. The transfer to Alfred Health was poorly coordinated without clear urgency indicators or recommended timeframes. Alfre…

psychiatryemergency medicinecommunicationsystemdextroamphetamine
WAhospital2025-12-23

Inquest into the Death of Karl Albert STEINHAUSER

30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…

… increasingly challenging management at Kalgoorlie Health Campus for acute psychotic exacerbation, he was transferred by RFDS to Fiona Stanley Hospital ICU, intubated due to severe agitation. He died post-extubation from…

psychiatryintensive caresystemdelayaripiprazole depot
VICmental health2013-06-12

Finding into death of Naomi Eva-May Hall

37y · Female·head injury sustained in motor vehicle collision (pedestrian)

A 37-year-old involuntary psychiatric patient with paranoid psychosis absconded from the low-dependency psychiatric unit at Maroondah Hospital and deli…

psychiatryemergency medicinesystem
NSWhospital2018-10-22

Inquest into the death of Sandra Cree

71y · Female·Ruptured abdominal aortic aneurysm, with coronary artery atherosclerosis contrib…

…ultants, and the receiving Dubbo hospital was not pre-alerted about the suspected aneurysm rupture. While transfer to a tertiary hospital may not have changed the outcome, early recognition and appropriate triage to a fa…

emergency medicinevascular surgerydiagnosticcommunicationgentamicin
NSWhospital2011-08-15

Coroner's Finding: Jacob Leonel Belim

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

…ur hours, and fluid resuscitation was inadequate. Jacob spent seven unnecessary hours at Liverpool before transfer to Westmead. At Westmead, surgery was delayed five hours despite clear septic peritonitis indicators. Pos…

emergency medicinegeneral practicediagnosticcommunicationampicillin
NSWhospital2021-06-24

Inquest into the death of William BERGER

74y · Male·Acute exacerbation of chronic airways disease, with carcinoma of prostate being …

…ned with chest pain, elevated troponin, and respiratory acidosis, a retrieval team was arranged. However, transfer to intensive care was deemed unsafe as intubation was contraindicated given his poor baseline lung functi…

respiratory medicineemergency medicinesalbutamol
TAShospital2016-07-18

Coroner's Finding: Henriksen, Wendy Margaret

72y · Female·probable sepsis complicating chemotherapy for non-Hodgkin's lymphoma

… Although a diagnostic laparotomy was appropriately not pursued given recent chemotherapy, the failure to transfer to ICU for maximal supportive care in early afternoon represented suboptimal care that reduced survival p…

emergency medicinesurgerydiagnosticdelaypiperacillin/tazobactam
NSWaged care2019-12-06

Inquest into the disappearance and suspected death of Raymond Speechley

77y · Male·Hypothermia

…facility included: failure to identify him as an absconding risk despite clear warning signs and hospital transfer documentation; inadequate handover procedures preventing communication of escalating absconding attempts;…

geriatric medicineemergency medicinecommunicationsystemrisperidone
WA2017-05-12

Inquest into the Death of Arulselvam VELMURUGU

35y · Male·bronchial asthma

…istmas Island immigration detention centre. He was initially identified as asthmatic at the jetty but not transferred to hospital. At the processing centre, he received oxygen, salbutamol and prednisolone from a nurse. D…

emergency medicinegeneral practicecommunicationsystemsalbutamol
WAmental health2017-06-22

Inquest into the Death of Annette SILVER

47y · Female·Multiple injuries from being struck by a train

…r-old woman with major depressive disorder and anxiety died by suicide while an involuntary psychiatric inpatient. She had attempted suicide in November 2014 and was admitted to Bentley Hospital for psychiatric treatmen…

psychiatrypsychologysupervisionsystemcitalopram
QLDhospital2018-09-26

Mann, Renae Jean

43y · Female·acute toxic effects of amitriptyline

…tal with suspected amitriptyline overdose. After 11 hours of ED monitoring, she was medically cleared and transferred to a mental health assessment pod, despite abnormal ECG findings with T-wave changes not fully investi…

emergency medicinepsychiatrydiagnosticcommunicationamitriptyline
VICaged care2018-12-10

Finding into death of Doris Clare Spratling

93y · Female·Haemothorax complicating rib fractures sustained in a fall

…om haemothorax and rib fractures sustained when a portable ceiling hoist became detached during a routine transfer in aged care. The hoist's safety latch disconnected from the strap linkage, causing her to fall from bed …

geriatric medicineemergency medicinesystem
SAhospital2015-03-06

Coroner's Finding: SIMOS Theodoras Joannas

48y · Male·undetermined

…psy revealed no specific cause of death. Key clinical lessons: rural hospitals managing acutely psychotic patients face significant complexity; early transfer via specialist retrieval (not RFDS/ambulance) may be prefera…

psychiatrygeneral practicesystemdelayhaloperidol
WAcommunity2016-01-06

Inquest into the Death of Gonda Alexandra SMITH

64y · Female·multiple injuries sustained in head-on motor vehicle collision

… nurse died in a head-on vehicle collision on a remote unsealed road whilst transporting a critically ill patient to hospital for emergency care. The coroner found that the primary cause was driver error—specifically, t…

emergency medicineoccupational and environmental healthproceduralsystem
TAShospital2021-06-07

Coroner's Finding: RA

17y · Male·massive head injury sustained in a fall from height (approximately 3.5 metres th…

…a false history of basketball injury) where CT imaging revealed significant intracranial bleeding. He was transferred by air ambulance to Royal Hobart Hospital for emergency hemicraniectomy but the injury was unsurvivabl…

emergency medicineneurosurgerysystem
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