Coronial

450 results for emergency procedures training

QLD2021-08-20

Caramin, Olivier Max - Non-inquest findings

27y · Male·multiple organ failure due to or as a consequence of heat stroke

…farm operator $100,000. Key preventive measures identified included thermal risk assessments, heat stress training, acclimatisation protocols, provision of shade structures, rescheduling to cooler times, and adequate sup…

occupational and environmental healthemergency medicinesystemdiagnostic
WAhospital2019-05-13

Inquest into the Death of Daniel Josef ADWENT

44y · Male·gunshot wound to abdomen

…were subsequently amended to ensure early consultant notification for major trauma patients, and improved training protocols for resuscitative procedures.

emergency medicinegeneral surgerycommunicationdelay
NSWcommunity2012-11-14

Inquest into the death of Roberto Laudisio CURTI

21y · Male·undetermined causes, in the course of being restrained by members of the NSW Pol…

Roberto Laudisio Curti, a 21-year-old Brazilian, died on 18 March 2012 during police restraint in Sydney after consuming LSD which induced a psychotic state. After a convenience store incident was misclassified as an arm…

psychiatrytoxicologycommunicationsystemLSD
VICcommunity2014-12-08

Finding into death of Craig Douglas

31y · Male·Gunshot wounds to chest

…hout coordination with colleagues or awaiting specialist CIRT response, was not in accordance with safety training principles and represented a contributing causal factor in the death. However, the coroner found that Dou…

communicationproceduralmethadone
WA2019-08-14

Inquest into the Death of Anita Jade BOARD

8y · Female·complications of multiple injuries sustained in motor vehicle crash

…hile attempting to exit through a side gate at excessive speed. Contributing factors included: inadequate training for a first-time driver; vehicle defects affecting brake function requiring excessive pressure beyond the…

emergency medicineintensive caresystemprocedural
VIChome2016-02-29

Finding into death of Chloe Kathleen Gent

0y · Female·Perinatal asphyxia

… verbally not to enter the pool alone, incorrect midwife contact details provided, lack of clarity about emergency procedures, and delays in midwife arrival. The coroner identified that while the precise aetiology of th…

obstetricsmidwiferycommunicationsystem
QLD2008-05-26

Rouse, Christine Chloe

2y · Female·Drowning (Fresh Water)

…ties should implement clear signage about supervision expectations; staff should receive formal lifeguard training; and emergency procedures must be established and rehearsed.

systemcommunication
NSWcommunity2018-07-30

Inquest into the death of Courtney Topic

22y · Female·gunshot wound to the chest

…hen fired, critical errors preceded this: responding officers failed to integrate mental health awareness training with tactical response, inattention to radio broadcasts indicating mental disturbance, lack of de-escalat…

psychiatryemergency medicinecommunicationsystemfluoxitane
VIC2020-02-11

Finding into death of Dianne Bradley

63y · Female·Multiple injuries sustained in a light plane incident

…he pilot-in-command be identified. Key clinical/operational lessons include: VFR pilots have insufficient training to manage inadvertent entry into instrument conditions; decision-making failures occurred despite awarene…

delaysystem
NSWhome2023-04-19

Inquest into the death of Anthony Gilbert

41y · Male·complications of acute alcohol intoxication

…s assessed him as not 'seriously affected'. Critical clinical lessons: police officers without toxicology training struggled to assess intoxication in chronic alcoholics who may mask severe impairment; family clearly ref…

forensic medicinetoxicologydiagnosticcommunicationalcohol
NSWcommunity2022-10-21

Inquest into the death of Rachel Martin

28y · Female·Multiple injuries sustained when struck by a truck on the M1 Pacific Motorway

…known transport risks (autism, propensity to remove restraints, requiring two carers), insufficient staff training and briefing, excessive fatigue (Rachel worked 27.5 continuous hours including overnight care alone with …

social workpaediatricscommunicationsystem
SAhospital2026-05-28

Coroner's Finding: Sargeant, Gary Dale

36y · Male·Drowning

…dequate supervision—the patient was left unsupervised despite Mental Health Act powers being invoked and emergency transfer arranged. Preventable factors identified: reading referral documentation before first consultat…

general medicinepsychiatrydiagnosticprocedural
NSWcommunity2022-02-18

Inquest into the death of SP

36y · Male·hanging

…ed suspended from a tree. The coroner's investigation examined whether improved communication and search procedures between NSW Ambulance and NSW Police could have altered the outcome. Key issues included: NSW Ambulance …

emergency medicineparamedicinecommunicationsystem
TAShospital2025-08-29

Coroner's Finding: Scott, Nicholas Aaron

26y · Male·shotgun wound of the chest

…led to react promptly when he fled. The escape was entirely preventable through adherence to established procedures. Scott subsequently became involved in a violent altercation and was fatally shot by David Coles. The co…

correctional healthemergency medicineproceduralcommunicationmethamphetamine
QLD2005-10-07

Creegan, Thomas

47y · Male·Myocardial ischaemia as a result of undiagnosed coronary artery disease; cerebra…

…te medical declaration forms. The coroner emphasised that medical fitness assessment, improved instructor training, standardised briefing protocols, better rescue procedures with oxygen capability, and enhanced diver sup…

diving medicineemergency medicinecommunicationprocedural
VIC2020-02-11

Finding into death of Donald Ernest Hateley

68y · Male·Multiple injuries sustained in a light plane incident

…/poor visibility). The coroner found systemic regulatory gaps: VFR pilots lack adequate instrument flight training for emergency situations, there is no requirement to identify the pilot-in-command during flight, and pil…

aviation medicinesystemdelay
QLDcommunity2024-02-15

TE PAA Aaliyah; ROBERTSON Cayenne Murial; COOLWELL Rayvenna Tyrone; BAREFOOT

Unknown·Multiple injuries sustained as passengers in a motor vehicle collision

…vention addressing trauma and socioeconomic disadvantage, and culturally appropriate family notification procedures for First Nations families. The deaths highlight systemic factors affecting young offenders including ch…

forensic medicineemergency medicine
NSWmental health2019-11-22

Inquest into the death of David Dungay

29y · Male·cardiac arrhythmia

…rily called the Immediate Action Team (IAT) to move him to a camera cell, despite no security or medical emergency existing. During the forceful cell transfer, David was repeatedly restrained in the prone position, comp…

psychiatryemergency medicineproceduralcommunicationmidazolam
QLD2017-02-10

Sloan, Dane Benjamin

24y · Male·Hypoxic ischaemic encephalopathy due to or as a consequence of being hanged

Dane Benjamin Sloan, a 24-year-old remand prisoner with mental health history including suicidal ideation, hanged himself in the Maximum Security Unit exercise yard at Brisbane Correctional Centre. Although CCTV monitore…

psychiatryemergency medicinesystemdelayamitriptyline
QLD2016-07-08

Poxon, Simon James

47y · Male·Hypovolaemic shock due to exsanguination from traumatic rupture of femoral arter…

…tween a bucket truck and knuckle boom when the truck was reversed by a 19-year-old yard hand with minimal training. The driver should have checked behind the vehicle or used a spotter—standard practice outlined in the Pl…

proceduralcommunication
156723

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.