Coronial

215 results for emergency triage

TAShospital2022-11-30

Coroner's Finding: Hughes, Ellis Newton

83y · Male·aspiration pneumonia

Ellis Newton Hughes, 83-year-old retired mining engineer with metastatic prostate cancer, sustained a femoral fracture in a fall on 5 February 2020. He underwent open reduction and internal fixation on 10 February 2020 a…

orthopaedic surgeryemergency medicine
VIC2013-10-21

Finding into death of Danielle Louise Meredith

8y · Female·Multiple injuries sustained in collision between semi-trailer and train at level…

…reas: (1) the driver and vehicle factors, (2) level crossing infrastructure and warning systems, and (3) emergency medical response. Key clinical findings include: Mr Scholl, an experienced driver familiar with the cros…

emergency medicinetrauma surgerysystemdelay
QLDhospital2007-12-07

Burgen, Deborah Denise

49y · Female·Intra-abdominal haemorrhage, septic and haemorrhagic shock as a result of a lapa…

Deborah Burgen died from intra-abdominal haemorrhage complicated by septic shock following delayed emergency surgery for bowel obstruction. She attended the emergency department six times over eleven days with ide…

emergency medicinesurgerydiagnosticdelayparacetamol/codeine
NSWhospital2010-05-31

Coroner's Finding: Isaraelu Pele

8y · Male·bacterial meningitis that had not been diagnosed by a number of clinicians who h…

Eight-year-old Isaraelu Pele died of bacterial meningitis missed by multiple clinicians despite three hospital presentations and two GP visits between 14–17 December 2007. Critical failures included: inadequate different…

general practiceemergency medicinediagnosticdelayparacetamol
NSWhospital2019-07-29

Inquest into the death of Naomi Williams

27y · Female·Septicaemia secondary to Neisseria meningitides infection

Naomi Williams, a 27-year-old Wiradjuri woman, died from meningococcal septicaemia on 1 January 2016. She presented to Tumut Hospital in the early hours with generalised aches and pains while pregnant. Despite vital sign…

emergency medicinegeneral practicediagnosticcommunicationparacetamol
VIChome2013-11-27

Finding into death of Andrew Gilmore

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

…s: HITH lacks vital sign monitoring; recurrent post-op pain warrants immediate consultant review not phone triage; family communication about escalation pathways was inadequate; information from parents was not conveyed …

general surgeryemergency medicinecommunicationdelayoxycodone
NT2024-06-12

Inquest into the death of Mr Dooley

37y · Male·Complications due to atherosclerotic heart disease and dyslipidaemia

Glen Dooley, a 37-year-old Aboriginal man, died of atherosclerotic heart disease and dyslipidaemia while in custody at Darwin Correctional Centre. His death was avoidable. He had abnormal ECGs in 2019 and 2022 that were …

cardiologygeneral practicediagnosticcommunicationatorvastatin
TASaged care2024-12-18

Coroner's Finding: Martin, Shirley Dorothy

91y · Female·exacerbation of behavioural and psychological symptoms of dementia following sur…

…d response were appropriate and adequate. A 3-hour 47-minute ambulance delay was attributed to appropriate triage categorisation, regional surge conditions, and staffing shortages. The death was not preventable.

geriatric medicineorthopaedic surgery
NT2010-04-22

Inquest into the death of Zephaniah Namundja

22y · Male·Blunt head injury occasioned when the deceased fell from a moving vehicle

…ommunication about apparent neurological improvement can misleadingly lower clinical urgency; and accurate triage of critical head trauma is essential for appropriate resource allocation and family counselling. The preve…

alcohol
SAhospital2010-06-03

Coroner's Finding: PROMNITZ Aileen Dawn

79y · Female·Sepsis due to urinary tract infection with Group B streptococci

…ident died of sepsis from urinary tract infection with Group B streptococci after waiting 6 hours in the Emergency Department without being seen by a doctor. She arrived at 8pm with normal vital signs, was triaged Prior…

emergency medicineinfectious diseasesdelaysystem
VIChome2022-09-07

Finding into death of Kim Rebecca Lynch

41y · Female·neck compression

…ve despite high-risk status; he absconded and met with Lynch. The AWOL procedure had gaps: the Psychiatric Triage Service wasn't notified, nominated contacts weren't contacted within 30 minutes, and the missing person in…

psychiatryemergency medicinecommunicationsystemmethadone
NSWcommunity2018-08-28

Inquest into the death of MB

64y · Male·Multiple injuries sustained after jumping from a height

…th later, as the severity of MB's condition was not communicated to Dr S.. Had the call been appropriately triaged, MB likely would have been seen the same day. Police negotiators responded professionally and compassiona…

psychiatrygeneral practicecommunicationsystemmirtazapine
WAhospital2016-12-16

Inquest into the Death of Ms DHU

22y · Female·staphylococcal septicaemia and pneumonia complicating osteomyelitis of a right 1…

Julieka Dhu, a 22-year-old Aboriginal woman, died on 4 August 2014 from staphylococcal septicaemia and pneumonia complicating osteomyelitis of a rib fracture sustained in April 2014. She was detained in police custody on…

emergency medicineinfectious diseasesdiagnosticcommunicationamphetamine
VIC2013-10-21

Finding into death of Geoffrey Ian McMonnies

50y · Male·Multiple injuries sustained in collision between semi-trailer and train

… insufficient to alert drivers unaware of approaching trains, particularly heavy vehicle operators); and emergency response (found Harold Long's transfer by fixed-wing aircraft without intensive care support may have co…

emergency medicinetrauma surgerysystemdiagnostic
VIChospital2022-09-27

Finding into death of Neville Ernest Mills

66y · Male·Ruptured abdominal aortic aneurysm

A 66-year-old man presented to the Emergency Department with left-sided abdominal pain on 14 July 2021. After waiting over 6 hours in a crowded ED wi…

emergency medicinegeneral surgerysystemdelayibuprofen
WAmental health2015-12-31

Inquest into the Death of Stephen Colin ROBSON

Unknown·Ruby Nicholls-Diver: ligature compression of neck (hanging); Carly Jean Elliott:…

Five psychiatric patients of Alma Street Centre died between March 2011 and March 2012. Two (Ruby Nicholls-Diver and Anthony Edwards) died within 24 hours of discharge; two (Carly Elliott and Michael Thomas) died shortly…

psychiatryemergency medicinediagnosticcommunicationclozapine
QLDhospital2014-12-08

Gulliver, Graeme Barry; Harrison, Joanne Lee; Morten, Aileen Margaret

21y · Male·Sepsis caused by Leptospirosis (Graeme Gulliver); Group A streptococcal meningit…

Three young patients died from severe bacterial infections at rural Queensland hospitals (Mossman and Atherton). All three received delayed diagnoses and treatment. The first patient (21-year-old with leptospirosis) pres…

emergency medicineinfectious diseasesdiagnosticsystem
VIChospital2019-02-05

Finding into death of Eliza Gill

18y · Female·Colchicine toxicity

…0.25mg/kg), below the guideline threshold of 0.5mg/kg used at that time for charcoal administration. The Emergency Department appropriately consulted poisons information but received advice based on outdated guidelines.…

emergency medicineintensive carediagnosticsystemcolchicine
VIC2010-05-28

Finding into death of Katherine Fiona Walton

47y · Female·insulin overdose

…fter overdose risk warrants closer follow-up, importance of comprehensive psychiatric risk assessment in emergency settings, attention to medication access in workplace settings, and identification of cumulative psychos…

emergency medicinepsychiatrycommunicationsysteminsulin
VICcommunity2025-09-05

Finding into death of R J

36y · Male·Heroin toxicity

…lessness and intravenous heroin use died from heroin toxicity after overdosing in a public toilet block. Emergency services were called promptly by a bystander who remained at the scene. However, paramedics were held at…

communicationsystemheroin
167811

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