Coronial
QLDhospital2019-07-24

Mr P - Non-inquest findings

47y · Male·Pulmonary thrombo-embolism secondary to deep vein thrombosis in setting of morbi…

…calf swelling. His GP appropriately suspected both pneumonia and pulmonary embolism (PE), requesting urgent CTPA. At Townsville Hospital's ICU, clinicians anchored on pneumonia as the diagnosis despite the requesting phy…

intensive careemergency medicinediagnosticcommunicationheparin
TAShospital2020-08-11

Coroner's Finding: Howard, Noeline Dawn

76y · Female·pulmonary embolism due to carcinomatosis

…Both diagnoses were incorrect. She had widespread cancer (carcinomatosis) with multiple pulmonary emboli. A CTPA was requested but could not be performed because she was unable to lie flat; no alternative investigation s…

emergency medicinerespiratory medicinediagnosticdelayintravenous fluids
VIChospitalNew2026-08-21

Finding into death of Susanne Keating

64y · Female·Presumed massive pulmonary embolus

…ng physicians appropriately considered PE as differential diagnosis and ordered appropriate investigations: CTPA, blood tests (D-dimer, troponin), and ECG. However, these critical tests were not performed during her 6-ho…

emergency medicinegeneral practicedelaysystem
NSWhospital2026-01-13

Inquest into the death of Paul Harris

43y · Male·Bilateral pulmonary thrombo-emboli; contributory factors included obesity, coron…

…ted in hospital records. Paul was never transferred to Griffith Base Hospital for CT pulmonary angiography (CTPA)—the only test that could have definitively diagnosed PE. The coroner found that PE should have been consid…

general practiceemergency medicinediagnosticcommunicationceftriaxone
VIChospital2023-02-28

Finding into death of Mrs K

81y · Female·Cardiac tamponade secondary to dissection of ascending aorta

…logy with suspected NSTEMI, and died from cardiac tamponade due to aortic dissection rupture while awaiting CTPA. The coroner found that aortic dissection was likely considered but discounted based on absence of 'classic…

emergency medicinecardiologydiagnosticdelayaspirin
VIChospital2018-10-18

Finding into death of Maxwell Norman Campbell

68y · Male·pulmonary thromboembolism in the setting of recent surgery

…vasovagal episode occurred post-shower at 10am but was reasonably attributed to post-operative recovery. No CTPA was performed prior to cardiac arrest at 12:30pm. The coroner found medical care was appropriate and the de…

bariatric surgerygeneral surgeryheparin
TAShospital2022-10-26

Coroner's Finding: Carroll, Terence John

71y · Male·sepsis caused by mediastinal empyema (abscess) which complicated perforation of …

…tively; diagnosis of perforation was delayed at the referring hospital (22 hours delay from presentation to CTPA confirmation); and the patient was discharged same-day despite being frail, cognitively impaired, hypotensi…

ENT surgerygeneral surgerycommunicationdiagnostic
SAhospital2020-05-21

Coroner's Finding: SNIECIKOWSKA Alicja

68y · Female·chronic obstructive pulmonary disease

…d trials of non-invasive ventilation (BiPAP), she demonstrated poor compliance, refused diagnostic imaging (CTPA), and became increasingly agitated. She was placed on a Level 1 Mental Health Inpatient Treatment Order aft…

respiratory medicineemergency medicinemorphine
NThospital2023-03-15

Inquest into the death of Janelle Pamkal

35y · Female·aortic dissection with associated acute aortitis

…as timely and the receiving ED team initiated appropriate chest pain investigation including troponin, ECG, CTPA and D-dimer testing. However, she suffered a rare Type A aortic dissection with acute aortitis, an extremel…

emergency medicinepsychiatryolanzapine
VIChospital2013-06-17

Finding into death of Trevor Edward Hammond

72y · Male·ischaemic heart disease secondary to coronary artery disease

…monary embolus diagnosis based on pleuritic-sounding pain and positive d-dimer, commencing anticoagulation. CTPA was negative and he was discharged with plans for outpatient cardiology review. He died at home the next da…

emergency medicinecardiologydiagnosticdelaydigoxin
TAScommunity2019-03-08

Coroner's Finding: Paraskevas, Odissefs

56y · Male·pulmonary thromboembolism due to left deep vein thrombosis

…ing given the patient's age >50 and heart rate >100 bpm. A positive D-dimer would likely have led to urgent CTPA, detection of PE, and anticoagulation therapy, offering the best prospect of survival. The case highlights …

general practicecardiologydiagnosticdelay
VIChospital2019-08-05

Finding into death of Carmel Killackey

77y · Female·Pulmonary thromboembolism secondary to deep vein thrombosis of the left leg

A 77-year-old woman with Factor V Leiden thrombophilia and history of PE presented to a rural urgent care centre on 19 April 2017 with shortness of breath and chest pain. She was examined by Dr H. who considered but dism…

emergency medicinegeneral practicediagnosticproceduralwarfarin
QLDhospital2023-06-26

Searle, William Edward

74y · Male·Aspiration of gastric contents due to paralytic ileus following Whipple surgery …

…NGT reinsertion; at 4:17am on 2 March despite clinical deterioration and abnormal blood work; and after the CTPA showing abdominal/oesophageal distension. Earlier reinsertion of the nasogastric tube, particularly on even…

general surgeryintensive carediagnosticcommunicationadrenaline

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.