Coronial

138 results for physical examination

QLD2014-09-09

MacDonald, Wayne

53y · Male·Multiple injuries due to blast injury from catastrophic tyre failure (zipper fai…

… suffered a 'zipper failure' due to previous under-inflation and inadequate integrity testing. Clinical examination revealed blast injuries (cerebral contusions, pulmonary collapse, pulmonary lacerations, fractured ribs…

systemcommunication
VIChospital2014-06-05

Finding into death of Constandia Petzierides

74y · Female·haemothorax secondary to dissecting thoracic aorta

Mrs Petzierides, a 74-year-old woman, presented to the emergency department with sudden-onset, severe left scapular pain radiating to the jaw, occurring shortly after midnight. She was assessed by an emergency medicine r…

emergency medicinecardiologydiagnosticcommunicationwarfarin
NSWhospital2016-12-22

Inquest into the death of Shona Hookey

29y · Female·peritonitis caused by ischaemia of the bowel due to gastrointestinal torsion (tw…

Shona Hookey, a 29-year-old Aboriginal woman with severe intellectual disability and aphasia, died of peritonitis secondary to bowel torsion. Critical failures occurred at multiple levels: carers at her group home delaye…

emergency medicineparamedicinediagnosticcommunicationparacetamol
NSW2024-05-17

Inquest into the death of Vicki Higgins

48y · Female·Ischaemic bowel, with contributing conditions of coronary artery disease, diabet…

Ms Vicki Higgins, a 48-year-old woman with diabetes, Crohn's disease (requiring ileostomy), and coronary artery disease, died from ischaemic bowel while in custody at Junee Correctional Centre on 29 January 2022, only 17…

general practicegastroenterologydiagnosticdelay
NSWhospital2018-02-27

Inquest into the death of Michaela Perrin

26y · Female·sepsis

Michaela Perrin, 26, died from sepsis arising from a post-caesarean wound infection caused by MRSA on 22 October 2014. She presented to the Emergency Department on 20 October with severe pain, tachycardia (125 bpm), and …

obstetricsemergency medicinediagnosticcommunicationceftriaxone
QLDhome2019-11-06

Follent, Mitchell James - Non-inquest findings

22y · Male·Multiple injuries from fall from height

Mitchell Follent, 22, died by fall from a third-floor balcony five days after discharge from his first psychiatric admission for post-ictal/drug-induced psychosis. He had intellectual disability, epilepsy, and acquired b…

psychiatryneurologydiagnosticcommunicationolanzapine
VIC2015-05-29

Finding into death of Ignac Lecek

68y · Male·Ischaemic small and large intestine complicating cardiogenic shock in the settin…

Ignac Lecek, 68, with hypertension and gout, collapsed in custody and died of ischaemic bowel complicated by cardiogenic shock in the setting of ischaemic heart disease. He complained of feeling ill on 2 October while in…

emergency medicinevascular surgerycommunicationsystemdiazepam
QLDaged care2024-08-15

Non-inquest findings into the death of Charlotte Paluszak

84y · Female·Complications associated with Diabetes Mellitus (likely hyperosmolar hyperglycae…

… pain; (4) better communication between GP and nursing staff on starting doses is crucial. The GP did not physically assess Mrs Paluszak or contact staff again after authorizing end-of-life care.

geriatric medicinepalliative caremedicationdiagnosticmorphine sulphate
QLDhospital2025-07-14

Non-inquest findings into the death of a two year old girl whose family was known to Child Safety

2y · Female·Complications of severe anaemia and SARS-CoV2 (COVID-19) infection

A two-year-old girl died from complications of severe iron-deficiency anaemia and COVID-19 infection. She had significant feeding difficulties, took almost exclusively milk and yoghurt, and was profoundly anaemic with po…

paediatricsemergency medicinediagnosticdelaymethamphetamine
QLDhome2026-04-21

Inquest into the deaths of F and M

33y · Male·Extensive burns sustained when former partner deliberately splashed petrol on hi…

…ly identification of perpetrator-victim dynamics in domestic violence cases, particularly recognising non-physical forms of coercive control and systems abuse; explicit assessment of risk to receiving parent when childre…

psychiatrypaediatricsdiagnosticsystem
QLD2005-10-07

Creegan, Thomas

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

…and ascending rapidly to the surface. He lost consciousness shortly after calling for help. Post-mortem examination revealed significant undiagnosed coronary artery disease (70% stenosis of the left anterior descending …

diving medicineemergency medicinecommunicationprocedural
WAhospital2017-03-21

Inquest into the Death of Masaly MOSBY

0y · Female·acute necrotising pneumonia

Masaly Mosby, a 36-day-old Aboriginal infant, died from acute necrotising pneumonia after presenting to Broome Hospital Emergency Department three times in four days but never being seen by a doctor for formal assessment…

emergency medicinepaediatricsdiagnosticsystemparacetamol
QLD2009-09-10

Blee, Jason George Elliott

33y · Male·Pelvic crush injury sustained while working at an underground coal mine

Jason Blee, a 33-year-old experienced miner and trainer at Moranbah North Mine in Queensland, was fatally crushed on 9 April 2007 when a shuttle car pinned him against a rib (wall) in a narrow underground heading. Follow…

occupational and environmental healthemergency medicinesystemdelay
QLDhospital2018-05-11

Orton, David - Non-inquest findings

41y · Male·Cerebral hypoxia and bronchopneumonia; contributing factors: toxic megacolon, ce…

David Orton, a 41-year-old man with cerebral palsy, intellectual disability, and severe kyphoscoliosis, died from cerebral hypoxia and bronchopneumonia complicated by toxic megacolon and Salmonella infection. Over 18 mon…

general medicinegastroenterologydiagnosticcommunicationmovical
TAShome2017-06-26

Coroner's Finding: Johnstone, BJay

0y · Male·Traumatic head injury

BJay Adam Johnstone, 45 days old, died from severe traumatic head injury inflicted by his father Simon Johnstone in a household environment. BJay suffered multiple episodes of violence including head trauma, rib fracture…

paediatricsemergency medicinediagnosticsystemcannabis
SAhome2022-04-21

Coroner's Finding: Rigney, Amber Rose and Mitchell, Korey Lee

Unknown·Amber Rose Rigney: external airway occlusion with compression of the neck; Korey…

Two children, Amber Rose Rigney (6) and Korey Lee Mitchell (5), were murdered on 30 May 2016 by their mother's partner Steven Graham Peet. The Coroner found their deaths were preventable. The children's mother had been u…

paediatricssystemdelayice/methamphetamine
NSWprison2021-11-19

Inquest into the death of Danny Whitton

25y · Male·Multiple organ failure due to acute paracetamol poisoning

… absent; there was no proper nursing documentation or care plan; and inappropriate reliance on a doctor's physical attendance delayed hospitalisation. By 7 November Danny had a Glasgow Coma Scale of 11 indicating serious…

emergency medicinetoxicologydiagnosticcommunicationparacetamol
VIChospital2023-05-16

Finding into death of Mathew James Luttrell

43y · Male·Hanging

…Hospital following a suicide attempt on 11 November 2018. He was placed on an Assessment Order, secluded, physically restrained and sedated with olanzapine after escalating behaviour at lunchtime. He was discharged the f…

psychiatryemergency medicinecommunicationdelayolanzapine

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