Coronial
NSW2022-02-18

Inquest into the death of Ricardo Damien Arquero

40y · Male·Bronchial Asthma

…athing difficulty in May 2019 treated appropriately. He collapsed while on the toilet and despite immediate CPR by officers and paramedics, could not be revived. The coroner found no evidence that any action by Correcti…

general practiceemergency medicinesalbutamol
VICcommunity2021-06-28

Finding into death of Maria Assunta Agius

56y · Female·Complications of motor neuron disease

…tion. She had a PEG tube for feeding and required nocturnal ventilation. An advanced care directive refused CPR, intubation, tracheostomy, and interventions causing excessive discomfort. She was found unresponsive on 12…

neurologypalliative care
VIC2010-05-24

Finding into death of Phillip William Banner

79y · Male·Ischaemic heart disease

…pain at 2:11am, a Code Black was immediately called, and MICA paramedics arrived within 26 minutes. Despite CPR for approximately 20 minutes during transport to St Vincent's Hospital, he did not respond. The coroner fou…

emergency medicinecardiology
TASaged care2017-11-29

Coroner's Finding: Plummer, Samuel Anthony

34y · Male·sudden unexpected death in a person with epilepsy (SUDEP)

…ly 2015. He was found unconscious in his bedroom approximately 45 minutes after retiring; despite immediate CPR and paramedic intervention, resuscitation was unsuccessful. Autopsy revealed peri-mortem tongue biting cons…

neurologypsychiatrysodium valproate
VICaged care2011-03-29

Finding into death of Jeanette Bramley

64y · Female·unascertained

…renia resident in aged care, was found unresponsive on the floor of her room and died despite 50 minutes of CPR. Post-mortem examination could not definitively establish a cause of death. She was prescribed Clozapine fo…

psychiatrygeriatric medicineclozapine
VIChome2020-02-04

Finding into death of Bruce John Camp

70y · Male·Pulmonary thromboembolus secondary to deep vein thrombosis

…ag symptoms. He collapsed early morning on 31 March 2019 while sitting with a carer, becoming unresponsive. CPR was initiated but unsuccessful. Post-mortem examination confirmed a large saddle pulmonary embolism origina…

general practiceemergency medicinerisperidone
TAShospital2017-06-12

Coroner's Finding: Paino, Sarah

Female·neck and chest injuries from motor vehicle crash

…promptly and medical staff at Royal Hobart Hospital performed an emergency Caesarean section during ongoing CPR, successfully delivering her baby. The criminal driver was convicted of manslaughter. This case highlights …

emergency medicineobstetricscannabis
TAScommunity2016-05-13

Coroner's Finding: Mr F

17y · Male·haemopericardium due to laceration of the heart

…scooter was mechanically sound. The attending paramedics and police, along with Mr F's friend who performed CPR, were commended for their efforts. The coroner found nothing more could have been done by ambulance personn…

VICaged care2013-10-29

Finding into death of Hussan Rushton

29y · Male·Bronchopneumonia in a man with epilepsy

…0 minutes later, carers found him unresponsive with bleeding from nose and mouth. Despite resuscitation and CPR by paramedics, he could not be revived. Autopsy confirmed bronchopneumonia in the left lower lobe, with evi…

general practicerespiratory medicine
SAaged care2024-05-22

Coroner's Finding: Hough, Robert John

72y · Male·asphyxia due to upper airway obstruction due to choking on food

…tients with neurological conditions affecting swallowing. Staff responded appropriately with back blows and CPR. The coroner made no recommendations.

neurologygeriatric medicine
TAScommunity2016-01-29

Coroner's Finding: Ordonez, Genaro Lotero

29y · Male·drowning

A 29-year-old Colombian tourist drowned at Swimcart Beach, Tasmania, after entering the water in unsuitable conditions. Unfamiliar with the beach and unaware of strong rip currents and large waves, he waded into shallow …

VICaged care2015-07-17

Finding into death of Fatima Lay

47y · Female·Pulmonary thromboembolism secondary to deep vein thrombosis

…ein thrombosis. She collapsed in the bathroom while under the care of facility staff who promptly initiated CPR and called emergency services. Post-mortem examination confirmed pulmonary thromboembolism and DVT as the c…

forensic medicinepsychiatryaripiprazole
NSW2022-03-07

Inquest into the death of Ali Kizildag

47y · Male·Acute opioid (Heroin) toxicity

…1 September 2018. He was found unresponsive in his cell after failing to return from a medical appointment. CPR was commenced immediately and ambulance attended within 12 minutes, but resuscitation was unsuccessful. The…

general practiceforensic medicineheroin
VIChome2024-12-09

Finding into death of Luana Janiece Ross

61y · Female·Alzheimer's Dementia and epilepsy in the setting of Down syndrome, hypothyroidis…

…being assisted with her morning routine and died shortly after. Paramedics responded promptly and initiated CPR, which was ceased following discussion with her family. The medical cause of death was Alzheimer's dementia…

general practiceneurology
VIC2022-06-16

Finding into death of Dennis Alfred Goudge

68y · Male·Complications of metastatic cholangiocarcinoma

…of 30 July 2021, he was observed sleeping at 3:00 am, but was found non-responsive and groaning at 5:00 am. CPR was commenced and paramedics attended, but he was declared deceased at 5:45 am. Post-mortem examination con…

oncologycardiology
VICcommunity2023-02-01

Finding into death of Do Hung Vu

65y · Male·Drowning

…ng and wheezing, and type 2 diabetes. He was found unresponsive on the seabed by other divers who performed CPR until paramedics arrived. The coroner noted significant over-representation of people from culturally and l…

VICmental health2012-01-23

Finding into death of Rosemary Jane Berg

55y · Female·metastatic lung cancer

…outweighing benefits. Ms Berg was assessed as competent to make treatment decisions and signed a refusal of CPR certificate. She chose to remain at the hospital rather than transfer to palliative care, where she receive…

oncologypalliative careantipsychotic medications
VICaged care2012-04-02

Finding into death of Leon James Thompson

64y · Male·Acute anterior myocardial infarction and coronary artery occlusion

…sident at an aged care facility. He was found unresponsive in an armchair outside his bedroom at 5:30am and CPR was commenced by staff but he could not be resuscitated. The coroner found no suspicious circumstances. Thi…

cardiologyemergency medicinedelaywarfarin
SAcommunity2023-10-13

Coroner's Finding: Adams, Michael Gerard

62y · Male·cardiac arrest complicating psychotic episode

…s after police arrival, paramedics did not detect that Adams had deteriorated into cardiac arrest, delaying CPR initiation. Critical failures included: inadequate observation while restraining (no clinician maintained h…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
VIChospital2021-09-30

Finding into death of James Owen Lynch

71y · Male·Aspiration pneumonia in a man with intellectual disability

…ber 2020, he was found collapsed at his supported residential service and could not be resuscitated despite CPR and intensive care support. The coroner found natural causes (aspiration pneumonia). Clinical lessons inclu…

emergency medicineintensive careamoxicillin
156719

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