Coronial

1,288 results for emergency treatment

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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
WAhospital2023-02-22

Inquest into the Death of Aishwarya Aswath CHAVITTUPARA

7y · Female·multiorgan failure due to fulminant sepsis (Streptococcus pyogenes)

…to fulminant sepsis (Streptococcus pyogenes) after approximately 90 minutes in Perth Children's Hospital emergency department. She presented with gastrointestinal symptoms, fever, cold extremities and lethargy but was t…

emergency medicinepaediatricsdiagnosticcommunication
WAhospital2015-02-13

Inquest into the Death of Christopher Ling TAO

2y · Male·Myocarditis secondary to Kawasaki Disease

Christopher Tao, aged 2 years 9 months, presented to Princess Margaret Hospital ED with a 5-day fever, cervical lymphadenopathy, rash, conjunctivitis, and other features diagnostic of Kawasaki Disease (KD) on 7 September…

emergency medicinepaediatricsdiagnosticcommunicationparacetamol
NSWhospital2022-12-08

Inquest into the death of Austin Facer

6y · Male·cardiopulmonary arrest on a background of earlier cardiac arrests and resuscitat…

… for clear interstate retrieval protocols between NSW and South Australia. The coroner found the medical treatment Austin received was appropriate, but systemic communication and coordination failures created avoidable …

paediatricsemergency medicinecommunicationsystemadrenaline
NSWhospital2024-10-11

Inquest into the death of AX

45y · Female·Multiple blunt force injuries

A 45-year-old woman with acute psychotic illness attended Prince of Wales Hospital ED on 4 August 2020 after presenting to police with persecutory delusions. She was assessed by mental health and medical clinicians who a…

emergency medicinepsychiatrydiagnosticcommunication
QLDhospital2016-09-02

Calder, Michael James

33y · Male·Opiate toxicity

A 33-year-old man with previously unrecognized obstructive sleep apnoea was admitted with severe headache. The treating physician prescribed a complex regimen of escalating opiate doses including both slow-release (MS Co…

general medicineemergency medicinemedicationdiagnosticmorphine
NSWhospital2023-08-21

Inquest into the death of Maureen Smith

75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis

…s pending joint aspiration at Armidale Rural Referral Hospital. However, critical delays occurred: a non-emergency transport booking was made, then transferred to NSW Ambulance around 3.15pm. At 5.07pm, ambulance crew d…

orthopaedic surgeryemergency medicinediagnosticcommunicationcorticosteroid injections
NSWmental health2025-08-13

Inquest into the death of Allyson Bailey

42y · Female·pneumonia with diffuse alveolar damage in the setting of mixed drug toxicity (Ba…

Allyson Bailey, a 42-year-old woman with complex polysubstance use disorder and borderline personality disorder, died from pneumonia with diffuse alveolar damage complicated by mixed drug toxicity (baclofen and pregabali…

emergency medicineintensive carediagnosticcommunicationbaclofen
ACT2026-02-12

Inquest Into The Death Of David Wood

62y · Male·cardiac arrest caused by hypothermia following prolonged exposure to extreme col…

Captain David Wood, an experienced helicopter pilot, fell into a concealed crevasse on the West Ice Shelf in Antarctica while conducting fuel cache operations. He was exposed to extreme cold (-14°C) and remained in the c…

aviation medicineemergency medicinediagnosticsystem
WAhospital2021-11-29

Inquest into the Death of Miss T (Name Subject to Suppression Order)

16y · Female·acute abdominal obstruction secondary to adhesions associated with severe pelvic…

…nal people presenting with abdominal pain, and the need for improved access to sexual health testing and treatment in this high-risk population.

emergency medicinegeneral practicediagnosticsystemcannabis
NSWcommunity2025-08-25

Inquest into the death of Ashley Paull

49y · Male·Multiple injuries sustained when struck by a truck

…tate assessments, and officers' unfamiliarity with alternative mental health intervention options beyond emergency detention.

psychiatryemergency medicinecommunicationsystemmethamphetamine
VIChome2013-11-27

Finding into death of Andrew Gilmore

17y · Male·intra-abdominal haemorrhage complicating partial pancreatectomy for traumatic pa…

Andrew Gilmore, a 17-year-old fit and well boy, suffered traumatic pancreatic rupture from a football injury on 9 May 2009. Distal pancreatectomy was performed at Alfred Hospital on 11 May. He was discharged to Hospital …

general surgeryemergency medicinecommunicationdelayoxycodone
NTcommunity2008-09-01

Inquest into the death of Peter Limbunya

78y · Male·pneumonia with dehydration and exposure to heat as contributing factors

Peter Limbunya, a 78-year-old Aboriginal elder, died from pneumonia complicated by dehydration and exposure after being left unattended at a remote airstrip following hospital discharge. He was not accompanied by a requi…

emergency medicinegeneral practicecommunicationsystem
QLDhospital2008-09-12

Neville, Elise Susannah

10y · Female·Head injuries due to fall from a bunk bed

Elise Neville, aged 10, fell from a non-compliant bunk bed and sustained a head injury. At her first ED presentation to Caloundra Hospital at 3:25am, Dr D.—a junior house officer 19 hours into a 24-hour shift—failed to p…

emergency medicineneurosurgerydiagnosticcommunicationmannitol
WAAugust 2024

Inquest into the Death of Matthew Francis LEACH

50y · Male·ligature compression of the neck (hanging)

Matthew Francis Leach, a 50-year-old man with longstanding alcohol dependence, depression, and a history of suicide attempts, died by ligature hanging in his cell at Hakea Prison shortly after being sentenced to 12 month…

psychiatrypsychologysystemdelayvenlafaxine
QLDaged care2024-10-10

Non-inquest findings into the death of Diane Margaret Crowther

76y · Female·multiple organ failure due to abdominal wall cellulitis (surgically treated)

Mrs Crowther, a 76-year-old obese woman with multiple comorbidities in residential aged care, died from multiple organ failure secondary to abdominal wall cellulitis. A critical care failure occurred when an old dressing…

geriatric medicineplastic and reconstructive surgerydiagnosticcommunicationhydrozole cream
NSW2018-07-13

Inquest into the death of Sony William Tran-Bui

33y · Male·complications of acute peritonitis caused by rupture of a duodenal ulcer

Sony William Tran-Bui, aged 33, died from acute peritonitis caused by a ruptured duodenal ulcer while in custody at Silverwater Correctional Centre in November 2013. The death was not preventable given the sudden, unexpe…

gastroenterologyemergency medicinecommunicationsystemdiazepam
SAhospital2006-01-12

Coroner's Finding: EVANS Shaun Michael

22y · Male·Mixed Diflunisal and Buproprion (Zyban) toxicity

A 22-year-old man presented to Royal Adelaide Hospital's Emergency Department after taking approximately 110 Zyban (bupropion) tablets as a suicide attempt. Unknown to tre…

emergency medicinetoxicologydiagnosticcommunicationbupropion
SAcommunity2005-03-14

Coroner's Finding: Ryan Kunmanara

Unknown·Multiple; Kunmanara Ward: neck compression due to hanging; Kunmanara Ken: exposu…

…e failed Ken; police search and rescue protocols were dangerously delayed (missing person not treated as emergency for 2+ days in 42°C heat); mental health services for Ryan and Cooper were reasonable but discharge plan…

psychiatryemergency medicinedelaysystempetrol
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
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