Coronial
WA2022-06-17

Inquest into the 4 Deaths at Mount Augustus

heat stroke (environmental exposure) / hyperthermia; Mr Buske: atherosclerotic h…

…d on Mount Augustus summit trail in 2019-2020 during hot weather conditions. All deceased experienced heat stroke with dehydration as the primary mechanism of death. The coroner identified inadequate pre-visit warnings, …

emergency medicineforensic medicinesystemcommunication
VIChospital2010-12-08

Finding into death of Antonio Totaro

81y · Male·Head injuries sustained in a motor vehicle incident (pedestrian) in a man with i…

An 81-year-old man with ischaemic cardiomyopathy, diabetes, previous stroke, and peripheral vascular disease was struck by a motor vehicle while crossing Cranbourne Road in Frankston…

trauma surgerycardiology
QLDhospital2012-12-07

Cooper, Gerry Maxwell

57y · Male·Hepatic encephalopathy, end stage liver failure, alcoholic cirrhosis, end stage …

Gerry Maxwell Cooper, a 57-year-old Aboriginal man imprisoned for 23 years, died in PAH Secure Unit from natural causes: hepatic encephalopathy, end-stage liver failure, alcoholic cirrhosis, and end-stage renal failure. …

nephrologyhepatologysystemasasantin
VICaged care2025-03-14

Finding into death of Maria Grazia Nardiello

90y · Female·Surgical repair of fractured neck of femur sustained in a fall complicated by CO…

Maria Grazia Nardiello, aged 90, died following surgical repair of a fractured neck of femur sustained in a fall at an aged care facility, complicated by COVID-19 infection. She was pushed by another resident with dement…

geriatric medicineorthopaedic surgerysystem
NSWcommunity2024-05-03

Inquest into the death of Keith Titmuss

20y · Male·exertional heat stroke

A 20-year-old professional rugby league player collapsed and died from exertional heat stroke after his first pre-season training session following an extended off-season break. Keith had the lowest a…

sports medicineemergency medicinesystemdelaymidazolam
VICaged carePodcast2019-08-23

Finding into death of John Reimers

63y · Male·complications of an inverted positional event (asphyxia from airway occlusion)

A 63-year-old man with previous stroke and left-sided paralysis fell headfirst into his bedside drawer while attempting to open it from his motor…

geriatric medicineemergency medicinediagnosticcommunicationduloxetine
VIChome2017-06-22

Finding into death of Steven Pimblett

47y · Male·Pneumonia

…ant health deterioration over two months—inability to walk, laboured breathing, swollen feet—and suspected stroke, but did not formally escalate concerns. The general practitioner visit two weeks before death noted only …

general practicepublic healthcommunicationsystem
WAcommunity2013

Inquest into the Death of Bradanovich, Anthony John

35y · Male·exertional heat stroke

…hway and becoming bogged in extremely hot conditions, he abandoned his vehicle and died of exertional heat stroke approximately 23km from Wiluna township. Critical systemic failures contributed to this preventable death:…

occupational and environmental healthemergency medicinesystemcommunication
SAaged care2026-02-12

Coroner's Finding: D Angelo, Adelina

88y · Female·Acute on chronic renal failure due to dehydration on a background of Lewy body d…

…r's visit on 3 October found lethargy and poor intake but failed to consider dehydration, missed-diagnosed stroke based on asymmetric tone, and mistakenly believed the patient was not for active treatment, delaying hospi…

general practicegeriatric medicinediagnosticcommunicationfurosemide
NSWaged care2011-05-20

Coroner's Finding: Iris Conyngham

91y · Female·traumatic subarachnoid haemorrhage and acute and chronic subdural haematoma as a…

91-year-old admitted to high-care aged care facility (Bennelong House) on 14 October 2009 following stroke and multiple falls. Within one hour of arrival, she fell from bed and lay on the floor for approximately 4…

geriatric medicineproceduralcommunication
WAprison2022-12-13

Inquest into the Death of William Frederick ANDERSON

53y · Male·intracerebral haemorrhage

William Anderson, an Aboriginal man aged 53, suffered a catastrophic intracerebral haemorrhage while imprisoned and died despite timely emergency response. Multiple delays occurred: 25 minutes before the cell was opened,…

emergency medicineneurologydelaysystemaspirin
VIChospital2024-11-08

Finding into death of Stephen Hills

65y · Male·Intracranial mass - glioblastoma multiforme

Stephen Hills, a 65-year-old NDIS participant in Specialist Disability Accommodation, died from glioblastoma multiforme after presenting with seizure-like symptoms on 11 April 2023. He was rapidly conveyed to hospital wh…

emergency medicineneurosurgery
VIChospital2019-11-11

Finding into death of Hilda Joan Berg

89y · Female·Aspiration pneumonia complicating electroconvulsive therapy for treatment of psy…

Hilda Berg, 89-year-old woman with depression, psychosis, atrial fibrillation, chronic kidney disease and type 2 diabetes, deteriorated in hospital with refusal to eat or drink due to psychotic beliefs. After initial con…

psychiatrygeriatric medicinecommunicationsystemolanzapine
VIChospital2021-02-05

Finding into death of Carl David Waldon

64y · Male·Left-sided intracerebral haemorrhage associated with deep brain stimulator wire …

…ract four days after elective neurosurgery for essential tremor. He was readmitted on day 4 with suspected stroke and started on therapeutic anticoagulation (enoxaparin). A haemorrhage developed within 24 hours of dose e…

neurosurgeryneurologymedicationsystemenoxaparin
QLDhospital2016-11-04

Neitsch, Horst - non-inquest findings

77y · Male·Stroke; cardiogenic shock; severe aortic stenosis with three vessel coronary art…

…ial ischaemia secondary to haemorrhage and his pre-existing severe coronary disease. He subsequently had a stroke and died on 29 May. The coroner identified multiple system failures in clinical communication, information…

cardiologyvascular surgeryproceduralcommunicationfurosemide
QLD2008-12-24

Trcka, Peter Joseph

54y · Male·Drowning after falling overboard from the Shanendale at Otter Reef

…. The coroner found he likely fell overboard, possibly after incapacitation from a medical event (seizure, stroke, or cardiovascular event). Clinical lessons include: the importance of medical assessment and possible med…

emergency medicineneurologysystemdelay
VIChospital2025-07-30

Finding into death of MHT

86y · Male·Complications of blunt force trauma in a man with cardiac amyloidosis and athero…

…sed with Alzheimer's disease and vascular dementia in 2019 and declined care services. His wife suffered a stroke in July 2022, leaving him without primary care. The family sought urgent assistance from multiple services…

emergency medicineneurosurgerysystemcommunicationondansetron
SAhospital2023-04-28

Coroner's Finding: Adams, Geoffrey Gordon

72y · Male·cerebral malignancy (glioblastoma multiforme)

Geoffrey Adams, aged 72, died in custody from glioblastoma multiforme (cerebral malignancy). He presented with acute neurological symptoms (slurred speech, facial droop, weakness) on 13 November 2020 during a routine med…

neurosurgeryradiologywarfarin
TAShospital2022-02-23

Coroner's Finding: Attwood, Maurice

86y · Male·hospital acquired pneumonia

…s including dysphagia with aspiration risk, severe malnutrition, asbestosis, pulmonary fibrosis, and prior strokes. The Coronial Medical Consultant found the hospital care was of good standard with appropriate multidisci…

orthopaedic surgeryintensive care
VIChome2016-02-09

Finding into death of Claire Denice Francis Parsons

66y · Female·plastic bag asphyxia

Dr P., aged 66, died from plastic bag asphyxia on 20 March 2014. She and her friend Valerie Seeger, who had Alzheimer's disease and heart disease, deliberately ended their lives together at home using nitrogen gas. Both …

178912

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