Coronial

364 results for CPR

WAhome2017-09-15

Inquest into the Death of Mary Josephine Van der WALT

28y · Female·ligature compression of the neck

… pulseless. They determined she was dead based on absent pulse and non-reactive pupils, so did not commence CPR. Paramedics arrived 6 minutes later, initiated CPR and adrenaline, and restored circulation after 15 minute…

emergency medicineintensive carediagnosticcommunicationdesvenlafaxine
NSWcommunity2024-02-19

Inquest into the death of Omar Mohammad

33y · Male·Irreversible hypoxic brain injury secondary to acute cocaine toxicity

…ed in informing paramedics about the ingested substance and the seizure activity. Police officers commenced CPR after approximately 5 minutes but ceased it after brief compressions, interpreting apparent gasping (agonal…

emergency medicinetoxicologycommunicationdelaycocaine
NSW2024-10-17

Inquest into the death of Kevin Edwards

41y · Male·Unable to be ascertained

…ice interaction early 5 June resulted in restraint; Kevin became unresponsive but officers did not commence CPR, believing shallow breathing was normal. Cause of death unable to be ascertained (potentially sudden cardia…

psychiatryemergency medicinediagnosticcommunicationmethamphetamine
VIC2014-03-06

Finding into death of Geoffrey Ashton

78y · Male·Ischemic heart disease

…ce station foyer; his second collapse occurred while in ventricular fibrillation. Critical delays occurred: CPR commenced only 5 minutes 49 seconds after collapse, and an automated external defibrillator (AED), though p…

cardiologypathologydelayprocedural
SAcommunity2010-04-01

Coroner's Finding: HALLORAN James Gordon

52y · Male·hypoxic-ischaemic encephalopathy due to cardiac arrest due to unknown aetiology

…vices by approximately 9 minutes, initially calling other doctors instead. When ambulance arrived at 18:07, CPR had only just begun and was of poor quality. Earlier paramedic involvement could have provided immediate re…

emergency medicineintensive caredelaycommunication
VIC2025-02-19

Finding into death of Mark Fava

46y · Male·Coronary artery disease

… coronary artery disease while in custody at Port Phillip Prison. He was found unresponsive in his cell and CPR was commenced immediately, continuing until paramedic arrival. The death was from natural causes with no su…

emergency medicinecorrectional healthamitriptyline
NSWaged care2021-09-22

Inquest into the death of Vakabauta LEONE

47y · Female·complications of rapidly progressing motor neurone disease

…on, residing in aged care. She collapsed at 1:00am with respiratory distress. Nursing staff did not attempt CPR, apparently believing an undocumented 'not for resuscitation' directive existed. No such directive was foun…

palliative careemergency medicinecommunicationdelay
WAhome

Inquest into the Death of Anthony William KUSTER

44y · Male·Ligature compression of the neck and methylamphetamine effect

…proximately 8 minutes later but, believing he was pretending (as had happened previously), did not initiate CPR immediately. Instead, he removed the tourniquet, took photographs, and spent considerable time examining th…

toxicologyforensic medicinedelaymethamphetamine
VICcommunity2013-12-20

Finding into death of Jade Lesley Dorogi

25y · Male·Cerebral hypoxia and multisystem organ failure from heroin (morphine) toxicity

…aniel Mobbs in a vehicle. Daniel, heavily drug-affected, failed to immediately call an ambulance or perform CPR, though he did eventually perform CPR when ambulance arrived. The coroner was unable to determine whether D…

forensic medicineemergency medicinedelayheroin
NSWaged care2020-07-29

Inquest into the death of John Pocklington

31y · Male·Acute Myocardial Infarction

…ia on 12 May, it would have identified cardiac risk. The immediate response to his collapse was appropriate—CPR commenced within 1.5 minutes by a nurse who was incidentally present, as corrections officers appropriately…

cardiologypsychiatrydiagnosticcommunicationmethamphetamine
WA2020-12-22

Inquest into the Death of Jordan Robert ANDERSON

23y · Male·hypoxic brain injury and bronchopneumonia complicating ligature compression of t…

…responsive: 3 minutes 40 seconds elapsed before his cell door was unlocked, and 9 minutes 50 seconds before CPR commenced. Systemic issues included: prison health staff were not notified when Anderson received punitive …

emergency medicinecardiologyproceduralcommunication
VICaged care2010-05-19

Finding into death of Beatrice Ivy Brown

80y · Female·Acute upper airway obstruction secondary to aspiration of food bolus

…ff rarely encounter medical emergencies and require comprehensive training in emergency response, including CPR technique and when to continue resuscitation; (4) communication failures during emergencies—including failu…

geriatric medicineemergency medicinecommunicationsystem
SA2023-05-12

Coroner's Finding: Morrison, Wayne Fella

29y · Male·Hypoxic ischaemic encephalopathy and multi-organ failure due to out of hospital …

…cardiac arrest occurred in the van. Clinical lessons include: mandatory training in restraint equipment and CPR is essential; standardized procedures for prisoner transport must exist; spit masks require specific protoc…

emergency medicineintensive caresystemdelay
NSWhospital2016-06-09

Inquest into the death of William MacDONALD

90y · Male·Complications arising from a gastrointestinal obstruction; incarcerated inguinal…

…onsultation determined his condition was not survivable and operative management was not appropriate. A 'No CPR' resuscitation plan was implemented based on clinical judgment that CPR would offer negligible benefit, con…

general surgerygeneral medicine
SAaged care2019-05-29

Coroner's Finding: FIELD Glenda Rae

59y · Female·Hypoxic-ischaemic encephalopathy due to acute upper airway obstruction

…ulties were identified and she was on a normal diet. When she collapsed while eating toast, staff initiated CPR immediately while she remained seated on the bench. Paramedics and MedSTAR attended; the doctor removed add…

emergency medicineintensive carefluoxenol
QLD2021-01-22

Miller, Cindy Leigh

44y · Female·Mixed drug toxicity (methylamphetamine, amphetamine, tramadol)

…sified as a 'Level 1' prisoner requiring hourly checks. At 1:35am, Constable Weibel found her unresponsive; CPR was commenced but she was likely already deceased. Clinical lessons include: inadequate CPR training of wat…

forensic medicineemergency medicinesystemproceduralmethamphetamine
QLDhome2015-03-23

R, aged one day - Non-inquest findings

0y · Female·meconium aspiration

…used only candles), preventing early detection of meconium in the birthing pool; perform effective neonatal CPR on an inappropriate surface; and promptly contact emergency services. The midwife had no formal neonatal re…

midwiferyneonatologydiagnosticprocedural
NTcommunity2017-06-29

Inquest into the death of John Munkara

44y · Male·coronary artery disease superimposed upon chronic obstructive pulmonary disease …

…uest or alert paramedics, delaying ambulance response by two hours. Police lacked facemasks in vehicles for CPR. Importantly, in May 2015, Munkara had been admitted under the Alcohol Mandatory Treatment Act but was unla…

emergency medicineparamedicinecommunicationsystemalcohol
WAprison2023-01-31

Inquest into the Death of Cally GRAHAM

31y · Female·hypoxic ischaemic encephalopathy, bronchopneumonia and myocardial ischaemia comp…

…layed ventilation despite protocols requiring it; (4) Her cellmate, an enrolled nurse, provided unprotected CPR rescue breaths for ~13 minutes, which likely prevented worse outcomes but should never be standard practice…

emergency medicineintensive caresystemcommunicationmethamphetamine
TAScommunity2023-05-23

Coroner's Finding: Vanderfeen, Jacinta

54y · Female·Blunt trauma of the head and chest caused by being crushed by a falling tree

…the tree and died rapidly from her injuries. Emergency responders, including a firefighter who administered CPR, attended promptly but extraction was delayed due to ongoing danger from additional unstable trees. This wa…

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