Coronial

332 results for emergency patient transfer

VIChospital2021-12-08

Finding into death of David John McDermott

70y · Male·Congestive cardiac failure in a man with ischaemic and hypertensive heart diseas…

…g surgical drainage. In September, he developed acute deterioration with worsening renal function and was transferred back to acute care. During admission, his agitation and refusal of medical treatment necessitated chem…

cardiologygeriatric medicineolanzapine
VIChome2024-08-08

Finding into death of Alan Edward Stewart

70y · Male·haemoperitoneum secondary to ruptured spleen following colonoscopy

…ziness and pallor, resulting in inappropriate advice to see a doctor within 12 hours rather than calling emergency services; (3) Had emergency care been accessed promptly, there was potential for life-saving interventio…

gastroenterologyemergency medicinecommunicationsystemparacetamol
NSWhospital2018-05-22

Inquest into the death of TM

5y · Male·complications of blunt force injury to the head

… but Mannitol was unavailable due to staff inability to locate it (though the drug was actually stocked). Transfer to paediatric neurosurgical care was significantly delayed due to aircraft issues and distance. The child…

paediatricsemergency medicinediagnosticdelaymannitol
NSWhospital2023-09-27

Inquest into the death of John O'Donnell

73y · Male·Complications of metastatic neuroendocrine lung carcinoma

…r accommodation; and failure to administer prescribed Lanreotide injections due to incomplete information transfer between healthcare providers. The coroner found that Justice Health failed to follow up discharge documen…

oncologypalliative carecommunicationsystemlanreotide
VICmental health2013-08-20

Finding into death of Hassan Yassin

35y · Male·Hanging

… an involuntary psychiatric admission. On 10 January 2011, following a clinical review at Broadmeadows In-Patient Unit assessing him as low suicide risk, Mr Yassin left the facility undetected. Critical failures include…

psychiatryemergency medicinecommunicationsystemrisperidone
NSWhospital2018-11-09

Inquest into the death of Alexander Costello

37y · Male·Haemopericardium secondary to aortic dissection

…cluded that at 3:30pm, after negative troponin results, aortic dissection should have been considered and transfer to Tamworth arranged. However, even with optimal transfer and surgical management, Costello likely would …

emergency medicinegeneral practicediagnosticcommunicationmorphine
TAShospital2024-10-11

Coroner's Finding: Vieth, Karl Heinz

92y · Male·periprosthetic fracture of the left hip sustained from a fall from standing posi…

…istory was admitted to Royal Hobart Hospital with chest pain and atrial fibrillation. He remained in the Emergency Medical Unit (EMU) for five days despite clinical deterioration, developing delirium and confusion. The …

general medicineemergency medicinesystemdelaymelatonin
NThospital2000-10-31

Inquest into the death of Marcio Jose Lay Nheu

26y · Male·Closed head injury with extradural and subdural haemorrhage resulting from a sku…

…e. He was struck by Rodney Foster during an altercation involving security guards. After police ambulance transfer, he was admitted to Royal Darwin Hospital's emergency department with a Glasgow Coma Score of 12, which i…

emergency medicineneurosurgerydiagnosticcommunicationtemazapam
VICaged care2023-06-27

Finding into death of Elizabeth Ethel Watson

89y · Female·Complications of fractured neck of femur in the setting of a fall in a woman wit…

…nd did not recognise the severity of injury. Although initial examination showed no obvious fracture, the patient deteriorated overnight with severe pain. Medical review by a locum at 5pm diagnosed only soft tissue inju…

geriatric medicineemergency medicinediagnosticcommunicationtramadol
SAhospital2026-04-23

Coroner's Finding: Wilson, Charles Thomas

85y · Male·Sepsis due to Staphylococcus aureus bacteraemia due to septic arthritis of left …

… While receiving generally adequate medical care, a critical medication error occurred when Mr Wilson was transferred to Port Augusta Prison: newly prescribed cardiovascular medications (bisoprolol and digoxin) were not …

cardiologygeriatric medicinemedicationcommunicationmetoprolol
WAhospital2005-11-25

Inquest into the Death of Waretini

46y · Male·Upper airway obstruction due to acute tonsillitis with laryngeal oedema and haem…

…out arranging handover of care or follow-up supervision with another accessible medical practitioner. The patient deteriorated with elevated respiratory rate and agitation; concerned nursing staff encouraged transfer to…

general practiceemergency medicinecommunicationsystempenicillin
NSWhospital2021-10-12

Inquest into the death of Bruce HODGES

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

…portunities for escalation; (3) The critical airway 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 …

emergency medicineENT surgerydiagnosticsystemnebulised saline
VIChospital2012-04-13

Finding into death of Joel Aaron Frigo

30y · Male·Haemopericardium caused by ruptured dissecting thoracic aortic aneurysm

…aortic dissection, but the attending physician dismissed this. Key clinical lessons: in Marfan's syndrome patients presenting with chest pain, aortic dissection must remain high in the differential despite atypical pain…

emergency medicinecardiologydiagnosticcommunicationatenolol
TAShospital2025-01-21

Coroner's Finding: Connlley, Maurice Gordon

76y · Male·Extensive small bowel infarction caused by superior mesenteric artery thrombus

…een ordered sooner; and there was a 3.5-hour delay between oral and written radiology reporting. Despite emergency transfer and multiple surgeries, the patient died from extensive small bowel infarction. The coroner acc…

emergency medicinesurgerydiagnosticdelayanticoagulant
VICmental health2014-07-07

Finding into death of Shamaoon Abdahad

62y · Male·Head injury (acute subdural haemorrhage and fractured skull)

A 62-year-old man with schizophrenia, lung cancer, and seizure history was an involuntary patient at Broadmeadows Psychiatric Unit. While supervised in the courtyard, he suddenly stopped walking then fel…

psychiatryneurosurgerysystem
VIChospital2020-05-05

Finding into death of John Hayle

76y · Male·Bronchopneumonia in a man with ischaemic heart disease and treated spinal crush …

…ugh this was not certain. Key lessons: delirium severely impairs clinical assessment; cross-institutional transfers require explicit communication of baseline neurological status; deterioration must be recognised against…

neurosurgerygeriatric medicinediagnosticcommunicationmk8931
VIChospital2014-07-10

Finding into death of TM Y

52y · Male·Hanging

… sobriety) and the ED junior doctor (who mistakenly believed the nurse had assessed him as low-risk). The patient was released back into the community with no money or means of transport. He died by hanging the followin…

emergency medicinepsychiatrycommunicationsystemalcohol
VIChospital2014-04-24

Finding into death of Stacey Jade Smith

20y · Female·Multiple injuries sustained when struck by train at Lalor Railway Station

Stacey Smith, aged 20, with complex psychiatric illness and suicidal ideation was transferred to Northern Hospital ED following confirmed overdose of 40-50 Valium tablets and explicit threats to t…

emergency medicinepsychiatrycommunicationsystemdiazepam
NSWcommunity2023-08-01

Inquest into the death of Peter Gretton

64y · Male·Complications of metformin toxicity on a background of undiagnosed renal impairm…

…dy established, appropriate escalation, clear communication with the on-call doctor, and timely ambulance transfer were failures. Key lessons: recognise that Yellow Zone vital signs require formal escalation pathways; im…

emergency medicinecardiologydiagnosticcommunicationmetformin
WAhospital2023-06-29

Inquest into the Death of Child R (Name Subject to Suppression Order)

11y · Female·Complications of E. coli sepsis in association with intestinal obstruction due t…

…tion at 8:30am; unclear handover of care between two doctors creating a gap in responsibility; failure to transfer to Broome Hospital until 11:40am when her condition was already critical; and unavailable age-related ref…

paediatricsemergency medicinediagnosticcommunicationmacrogol
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