Coronial
QLDhospital2016-02-17

Dickinson, Rick Dudley

55y · Male·Cardiac tamponade due to ruptured aortic dissection (Type A) against a backgroun…

Rick Dickinson, a 55-year-old man, presented to St Andrew's War Memorial Hospital after experiencing severe central chest pain and lower back pain with numbness at the gym. The treating senior doctor failed to adequately…

emergency medicinepathologydiagnosticcommunicationmorphine
QLDmental health2026-01-29

Inquest into the death of Tiesha Marie Derbyshire

18y · Female·Mixed drug toxicity

Tiesha Marie Derbyshire, an 18-year-old with complex mental health conditions including eating disorder, PTSD, and borderline personality disorder, died from mixed drug toxicity after intentionally overdosing on proprano…

psychiatrygeneral practicecommunicationsystempropranolol
WAmental health2024-07-19

Inquest into the Death of Phillip Benjamin VELTMAN

49y · Male·Unascertained - cardiac arrhythmia with terminal aspiration in an overweight man…

…been given. This omission meant standard post-Acuphase monitoring protocols were not implemented. While the ECG showed mild QT prolongation (490msec), experts agreed this was within acceptable range. The patient died un…

psychiatryemergency medicinecommunicationsystemketamine
WAhospital2018-03-15

Inquest into the Death of Roderick Leslie CARTER

63y · Male·Atherosclerotic Heart Disease

… and numbness). Although a registered nurse appropriately triaged him as ATS 2 (high priority) and obtained ECGs showing acute myocardial infarction within 15 minutes, she prioritised completing documentation before con…

cardiologyemergency medicinecommunicationsystemaspirin
VIChospital2021-07-20

Finding into death of Barry Brown

56y · Male·Internal blood loss, complications arising from laparoscopic cholecystectomy

Barry Brown, a 56-year-old man, died from internal bleeding after laparoscopic cholecystectomy due to critical systemic failures in post-operative care and diagnosis. Following hypotension at 7:30pm, nursing staff failed…

general surgeryintensive carediagnosticcommunicationnoradrenaline
NSWhospital2022-12-08

Inquest into the death of Austin Facer

6y · Male·cardiopulmonary arrest on a background of earlier cardiac arrests and resuscitat…

Austin Facer, a 6-year-old boy, suffered multiple cardiac arrests at school on 21 October 2019, initially resuscitated successfully, but died during transfer preparation to a higher-level hospital that evening. Autopsy r…

paediatricsemergency medicinecommunicationsystemadrenaline
VIChospital2023-07-17

Finding into death of Sasha

12y · Female·Hypoxic ischaemic encephalopathy complicating an aortic root abscess (operated) …

…th consensus that endocarditis diagnosis was unreasonably difficult given non-specific presentation, normal ECG/imaging, and rarity of pneumococcal endocarditis.

paediatricsinfectious diseasescommunicationsystem
NSW2019-11-08

Redacted findings in the joint inquest into deaths arising at music festivals including annexures - 8 November 2019

[18, 21, 23, 19, 22, 19]y · ["male", "female", "male", "male", "male", "female"]·MDMA toxicity (one case mixed MDMA and cocaine toxicity)

This inquest examined six deaths from MDMA toxicity after electronic dance music festivals in NSW between December 2017 and January 2019: Hoang Nathan Tran (18), Diana Nguyen (21), Joseph Pham (23), Callum Brosnan (19), …

emergency medicineintensive carecommunicationproceduralMDMA
WAhospital2022-01-25

Inquest into the Death of Carole LIVESEY

54y · Female·unascertained

Carole Livesey, a 54-year-old woman with severe anorexia nervosa and major depression, absconded from Rockingham Hospital psychiatric unit on 3 October 2017 during an escorted walk in hospital grounds. She had been an in…

psychiatrygeneral medicinecommunicationproceduralfluoxetine
VIChospital2011-07-29

Finding into death of Marlene Kenny

64y · Female·Bilateral pulmonary embolism with left middle cerebral artery/posterior cerebral…

Marlene Kenny, 64, presented to Orbost Hospital on 8 January 2007 with chest tightness, breathing difficulties and low oxygen saturation (83-86%). A doctor diagnosed panic attack and discharged her without investigation.…

emergency medicinegeneral practicediagnosticcommunicationdiazepam
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