Coronial

215 results for emergency triage

TAShospital2023-04-03

Coroner's Finding: RS - de-identified

1y · Female·infarction and volvulus of the small intestine due to adhesion from prior nephre…

A 19-month-old girl with history of Wilms tumour presented to Launceston General Hospital with vomiting, pain and lethargy. A Children's Early Warning Tool score of 6 triggered mandatory protocols including senior doctor…

emergency medicinepaediatricsdiagnosticsystem
SAhospital2017-06-22

Coroner's Finding: BAARTSE Leila Marijke

9y · Female·peritonitis due to perforated small bowel due to blunt abdominal trauma

Nine-year-old Leila Baartse-Harkin died from peritonitis due to a perforated small bowel sustained when she fell from a swing. Despite three medical encounters within 36 hours, the perforation was never diagnosed. At a r…

emergency medicinepaediatricsdiagnosticcommunicationparacetamol
NThome2022-06-10

Inquest into the death of Roberta Curry

28y · Female·hypovolaemia due to spleen laceration due to blunt force trauma to the torso

Roberta Curry, 28, was killed by her former partner Lorenzo Deegan after repeated assaults, with a fatal blow causing splenic laceration. Critical failures included: police misclassifying her 000 calls as general disturb…

emergency medicineforensic medicinecommunicationsystem
NSWhospital2019-02-07

Inquest into the death of Sharon Bell

53y · Female·cardiorespiratory arrest in a person with blunt force head injury, end-stage liv…

Sharon Bell was found dead in her hallway on 25 May 2013 aged 53. She had end-stage liver disease with hepatic encephalopathy, had suffered recent blunt force head injuries of unclear origin, and had high blood methadone…

emergency medicineforensic medicinediagnosticcommunicationmethadone
QLDhospital2009-12-08

Congoo, Sharon Faye

40y · Female·Bacterial septicaemia from an unknown organism

Sharon Faye Congoo died from overwhelming bacterial septicaemia of unknown origin at age 40. She presented to Mareeba Hospital (a small rural facility) on three occasions with non-specific viral-like symptoms and leg pai…

emergency medicineintensive caresystemcommunication
NSWhomePodcast2015-06-26

Inquest into the death of Tony BUGEJA (n/a,PDF File)

50y · Male·Acute anaphylactic reaction due to wasp sting

Tony Bugeja, a 50-year-old man with severe wasp sting allergy, died from anaphylactic shock after being stung at his home in Wilberforce, NSW. He was alone, used an expired EpiPen that appeared ineffective, and called tr…

emergency medicineallergy and immunologydelaysystemadrenaline
NSWhome2025-12-17

Inquest into the death of MQ

55y · Female·acute necrotising bronchopneumonia

MQ, 55, died of acute necrotising bronchopneumonia on 2-3 March 2023. She had developed community-acquired pneumonia from 21 February 2023, presenting initially with referred shoulder pain (later recognised as diaphragma…

general practiceemergency medicinediagnosticdelay
WA2020-11-19

Inquest into the Death of Levi Shane Clement CONGDON

27y · Male·methylamphetamine toxicity

…d this term to St John Ambulance paramedics, resulting in miscategorisation of priority. The ambulance was triaged as Priority 3 (non-urgent) and later Priority 2 (urgent) rather than Priority 1 (life-threatening). Polic…

emergency medicinetoxicologycommunicationsystemmethamphetamine
VIChospital2009-12-08

Finding into death of Timothy Jack Wood

1y · Male·Cerebral anoxia caused by cardiac arrest caused by bronchiolitis and bronchopneu…

Timothy Wood, a 19-month-old boy, died from cerebral anoxia following cardiac arrest caused by bronchiolitis and bronchopneumonia secondary to influenza A infection. He initially presented with croup symptoms on 15 July …

emergency medicineintensive carecommunicationsystemprednisolone
WAhospital2017-01-20

Inquest into the Death of Tamika Patricia Carol ULLRICH

23y · Female·chronic hydrocephalus with brain swelling

…en indicated. Systemic issues at the hospital regarding ED medical leadership, role clarity, and lack of emergency medicine training were identified as contributing factors. The death was not reasonably preventable give…

emergency medicinegeneral practicediagnosticcommunicationcelecoxib
WAAugust 2024

Inquest into the Death of Robert Allan EXELL

55y · Male·Complications of liver cirrhosis and hepatocellular carcinoma in a man with mult…

…alliative care. The coroner noted improvements have since been made to prison medical continuity and nurse triage processes.

hepatologygastroenterologydelaysystemmorphine
NSW2017-02-03

Inquest into the death of Thanh PHAM

30y · Male·traumatic brain injury

…ring. Critical clinical lessons include: (1) the failure to communicate vital head injury information to emergency services—witnesses knew he had hit his head heavily but ambulance operators were not informed, potential…

neurosurgeryemergency medicinecommunicationsystem
QLD2022-09-02

Mitchell, Vanelee Curtis

30y · Male·Sudden unexpected death in epilepsy

Vanelee Mitchell, a 30-year-old First Nations man with epilepsy, died suddenly in custody at Townsville Correctional Centre on 10 April 2020. He had suffered a head injury in 2014 resulting in acquired brain injury and s…

neurologycorrectional healthsystemsodium valproate
VIChospital2014-12-16

Finding into death of Michael Justin Nicoll

36y · Male·Multiorgan failure complicating Streptococcus pyogenes septicaemia

…e of probabilities. Cabrini Health acknowledged the discharge decision was erroneous and implemented the Emergency Department Safe Patient Discharge Program, staffing changes, and documentation improvements.

emergency medicineintensive carediagnosticsystemondansetron
NSWhome2025-05-09

Inquest into the death of Malcolm Brown

33y · Male·sharp force injuries of the neck

…s of managing acute mental health crises with substance intoxication, importance of information-sharing in triage decisions, and the role of trained negotiators in de-escalation.

psychiatrytoxicologycommunicationdelaymethamphetamine
WAhospital2025-03-06

Inquest into the Death of Jalen Hunter NORRIS

23y · Male·Multiple injuries from being struck by train

Jalen Hunter Norris, aged 23, died by suicide when struck by a train on 9 April 2021. He was experiencing paranoid delusions and had recently been arrested for criminal damage and cannabis possession after an incident at…

emergency medicinepsychiatrycommunicationdiagnosticcannabis
VIChome2015-10-08

Finding into death of Bruce Desmond Andrews

60y · Male·medication overdose

Bruce Andrews, a 60-year-old man with major depression and anxiety, died from medication overdose following relationship breakdown and acute alcohol intoxication. He fell from his porch, called his granddaughter reportin…

psychiatryemergency medicinecommunicationdiagnosticclonazepam
NSWhospital2019-12-13

Inquest into the death of Luca RASO

13y · Male·Peritonitis secondary to ruptured gangrenous acute appendicitis

Luca Raso, a healthy 13-year-old boy, died from peritonitis secondary to ruptured gangrenous acute appendicitis after being misdiagnosed with viral gastroenteritis by his GP on two consultations (22 and 24 February 2017)…

general practiceemergency medicinediagnosticcommunication
SAhospital2018-07-12

Coroner's Finding: MITCHELL Wayne Brian

49y · Male·ischaemic heart disease with coronary artery thrombosis (left main stem coronary…

Wayne Mitchell, a 49-year-old man, presented to a clinic with acute chest pain radiating to his jaw, accompanied by dizziness, diaphoresis, and dyspnoea. His symptoms resolved before ambulance arrival. The paramedics per…

cardiologyemergency medicinediagnosticcommunication
VIChome2023-01-23

Finding into death of Cody Morrella Watson

19y · Female·Hanging

Cody Watson, 19, died by hanging following childhood sexual abuse, family violence, and inadequate trauma-informed care. She disclosed abuse at 15, subsequently developing borderline personality disorder, anxiety, depres…

general practicepsychiatrysystemdelayvenlafaxine
178911

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