329 results for “delivery”
37y · Female·Blunt force head injuries
Sarah Tonkin, 37, died when a tow hitch assembly became dislodged from an Isuzu truck and struck her vehicle head-on, causing severe head injuries. The hitch pin securing the tow hitch was not properly installed during t…
18y · Male·Multiple blunt force injuries from motor vehicle collision
An 18-year-old driver died after his vehicle collided with a school bus while running a stop sign at 139-150 km/h. A police officer had begun following his vehicle without warning devices activated to conduct a traffic s…
Infant W: asphyxia due to accidental overlay by parent in unsafe sleeping enviro…
…ially preventable through proper risk assessment, application for court protection orders, and consistent delivery of safe sleeping guidance. Recommendations focus on CSS policy adherence, staff training, inter-agency co…
30y · Male·Ischaemic heart disease and coronary artery atherosclerosis
A 30-year-old male prisoner died of ischaemic heart disease with coronary artery atherosclerosis. He had a history of cannabis and methamphetamine use, anxiety, and asthma. While in custody, he was prescribed methadone, …
26y · Male·Suffocation due to inhaling nitrous oxide
A 26-year-old man died from suffocation after intentional recreational nitrous oxide use via a full-face gas mask connected to a cream whipper dispenser. He had purchased 300 cream chargers plus a 640g tank online two da…
0y · Male·Sudden Infant Death Syndrome (Category 2 - unexplained)
… home visits) is critical to prevention. The coroner recommended alignment of health promotion advice and delivery of consistent safe sleep messaging at key developmental milestones. While the specific death remains unex…
41y · Male·Stab wound to the chest
Jack, a 41-year-old man with extensive history of domestic violence perpetration across multiple relationships, died from a stab wound to the chest inflicted by his partner Sally during a domestic disturbance. Sally had …
64y · Male·Hypostatic bronchopneumonia complicating end stage Parkinson's disease
…anagement plans for complex disabilities and better communication between specialist assessments and care delivery.
Male·non-specific interstitial pneumonia
Simon John Sharpe, a sentenced prisoner with incurable non-specific interstitial pneumonia, died on 30 June 2017 at Fiona Stanley Hospital from progression of his lung disease. Throughout his 17-month imprisonment, Sharp…
71y · Female·Diffuse Lymphoid Malignancy
Mary Una Barnett, a 71-year-old woman in custody at Dame Phyllis Frost Centre, died from diffuse lymphoid malignancy (high-grade lymphoma) discovered shortly before her death. She had extensive comorbidities including ch…
26y · Male·Drowning
Jil Khokhara, a 26-year-old international student from India, drowned at Marengo Beach, an unpatrolled, extremely hazardous beach with strong currents and large breaking waves. He was unable to swim competently and enter…
50y · Male·Cerebral hypoxia and bronchopneumonia post episode of choking
Gregory Donald Cole, age 50, was a Wyndham Lodge aged care resident with significant disabilities including post-stroke paralysis and dysphagia requiring modified diet. He died on 25 June 2009 from cerebral hypoxia and b…
54y · Male·aspiration pneumonia caused by multiple drug toxicity
…e unusual Fentanyl PCA order; ward nurses failed to recognise the danger of combining two opioid modes of delivery; and Dr K. did not investigate when seeing Paul wearing the patch and PCA on the evening of surgery. The …
38y · Female·Streptococcus Group A Septicaemia (Post Partum-Puerperal Sepsis)
…childbirth at Osborne Park Hospital. She developed fever (38°C) at 3am on 5 April, only three hours after delivery. Despite multiple clinical warning signs including repeated elevated temperatures (38.7°C at 6:50am), sev…
67y · Female·perforated sigmoid volvulus with peritonitis upon a background of spinocerebella…
Betty Irene Ball, aged 67, died from perforated sigmoid volvulus with peritonitis on 2 February 2016. She had spinocerebellar ataxia and was resident in aged care. She developed constipation from 15 January 2016, but med…
41y · Male·Cardiomegaly in a man with WHO Class III obesity
…-up after medical episodes. The coroner found multiple opportunities for improvement in prison healthcare delivery, particularly regarding Aboriginal prisoners' access to culturally safe, continuous, equivalent care mode…
Female·Multiple causes: Ruby Natasha Nicholls-Diver: ligature compression of neck (hang…
…ch 2012). Two died within 24 hours of discharge, demonstrating critical failures in mental health service delivery. Key clinical lessons: (1) Individual management and risk assessment plans must be documented for all pat…
26y · Male·multiple injuries sustained in a motor vehicle accident
Nicholas Konedaris, 26, died in a motor vehicle collision on the Stuart Highway near Alice Springs when an oncoming vehicle crossed the centre line and struck his car head-on. The collision was initiated by momentary ina…
60y · Male·Mixed drug (methylamphetamine, deschloro-n-ethyl-ketamine) toxicity in a man wit…
Mr XML, aged 60, died from mixed drug toxicity (methylamphetamine and deschloro-n-ethyl-ketamine) in the setting of significant cardiovascular disease. He collapsed after self-injecting an unknown substance while driving…
59y · Male·Massive aspiration in the setting of intubation following complications of sever…
A 59-year-old man with treatment-resistant schizophrenia on long-term clozapine therapy died from massive aspiration following a severe ileus of unknown aetiology. He had documented constipation managed with laxatives, t…
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