Coronial
QLDhome2007-05-25

Skardoon, Dorothy Rae

82y · Female·Haemorrhage as a consequence of a compound fracture to the left ankle as a conse…

…kle sustained in a fall down stairs at her home on 24 May 2006, the same day she underwent a fluorescein angiogram for macular degeneration. The coroner's investigation examined whether the eye procedure contributed to …

ophthalmology
TAShospital2017-03-31

Coroner's Finding: Hoskinson, Neville Robert

55y · Male·cardiac tamponade resulting from proximal aortic dissection due to hypertension

…evere chest pain, headache and jaw pain to a regional hospital was evaluated for aortic dissection. A CT angiogram was performed but the radiologist's verbal report contained ambiguities and omissions compared to the wr…

emergency medicinecardiologydiagnosticcommunicationmorphine
SAhospital2013-04-08

Coroner's Finding: MAY Terrill Anthony

69y · Male·subarachnoid haemorrhage with contributing cardiomegaly

…vere headache, photophobia, nausea and neck stiffness—classic features of subarachnoid haemorrhage. A CT angiogram identified a 6mm aneurysm on the anterior communicating artery. The general practitioner sent a detailed…

emergency medicineneurosurgerydiagnosticcommunicationperindopril
VIChospital2023-08-01

Finding into death of Michele Valentino

81y · Male·Head injury sustained in a fall

…om a head injury sustained in a fall on 20 December 2019, with death occurring on 24 December 2019. A CT angiogram at 3:45pm showed worsening intraventricular haemorrhage (IVH) that was not identified by the neurology c…

emergency medicineradiologydiagnosticcommunicationaspirin
VIChospital2011-05-24

Finding into death of James Lawrence Williams

62y · Male·Extensive liver tumour, primary site not identified

James Williams, a 62-year-old man with intellectual disability, presented to his GP with tiredness, anorexia and fever. Initial assessment suggested possible hepatitis and he was referred to hospital. CT imaging revealed…

general practiceemergency medicine
VIChospital2013-11-18

Finding into death of Sean Raymond Adams

51y · Male·Multiorgan failure in a man with corrected congenital coarctation of the aorta a…

Sean Raymond Adams, 51-year-old male with complex cardiac history including corrected coarctation of aorta, valvular disease, and biventricular heart failure, presented to Alfred Hospital ED with chest pain and dyspnoea.…

cardiologyemergency medicinecommunicationsystemhaloperidol
SAhospital2004-11-18

Coroner's Finding: PEDDEY Ross Dudley

63y · Male·pneumonia complicating anoxic brain injury, due to post-operative haemorrhage as…

…tely delegated care to a first-year intern (Dr K.) and left for clinic without follow-up. A CT pulmonary angiogram was pursued despite low clinical probability, delaying diagnosis until cardiac arrest occurred. Earlier …

colorectal surgerygeneral surgerydiagnosticdelaywarfarin
TAShospital2024-08-05

Coroner's Finding: Whitney, David Ian

73y · Male·sepsis due to ischemic gut due to occlusion of the superior mesenteric artery

…sented with acute severe abdominal pain caused by superior mesenteric artery (SMA) occlusion. Initial CT angiogram at 12:30am was reported as normal; the SMA occlusion was not identified until 4:45am—over 4 hours later—…

emergency medicineradiologydiagnosticcommunication
TAShospital2023-06-13

Coroner's Finding: HN de-identified

83y·cardiac tamponade due to haemopericardium resulting from traumatic parietal peri…

…resented to the ED with chest pain and was found to have a pericardial effusion. She underwent an aortic angiogram but critical investigations including echocardiography were not clearly documented. A pericardiocentesis…

emergency medicinecardiologyproceduralsystem
WAhospital2020-04-24

Inquest into the Death of Hassan BECHARA

52y · Male·ischaemic heart disease

Hassan Bechara, a 52-year-old prisoner, died from ischaemic heart disease in July 2017. He had complex cardiac history including dilated cardiomyopathy, triple-vessel coronary disease, and previous cardiac procedures. Cl…

cardiologyemergency medicinedelaysystematorvastatin
SAhospital2006-12-14

Coroner's Finding: PETTER Elemer

79y · Male·myocardial infarction

A 79-year-old man with significant comorbidities (ischaemic heart disease, diabetes, peripheral vascular disease) was admitted to hospital with anorexia and weight loss. He developed acute confusion and delirium, initial…

cardiologypsychiatrycommunicationhaloperidol
SAhospital2010-02-04

Coroner's Finding: KRIVITCH Olga

81y · Female·hypovolaemic shock following bleeding from the site of a femoral angiogram

Olga Krivitch, 81-year-old woman, died from hypovolaemic shock caused by bleeding from her femoral angiogram puncture site. She was admitted for ischaemic leg and underwent unsuccessful thrombolytic therapy. Subse…

vascular surgeryradiologydiagnosticmedicationheparin
VIChospital2020-02-28

Finding into death of Keith Walter Sharp

63y · Male·Cerebral infarction complicating vertebral artery dissection following motor veh…

…ging at 10:44am identified significant cervical spine injuries, but critical imaging results (MRI and CT angiogram) were delayed approximately 4.5 hours. The patient deteriorated acutely around 5:15pm during further ima…

emergency medicineradiologydelaydiagnosticaspirin
SAhospital2008-09-19

Coroner's Finding: ALLEN Richard Grant

60y · Male·haemopericardium due to rupture of right ventricle complicating removal of cardi…

…e (situated 100 metres away), leading to a 20-25 minute diagnostic delay while an unproductive pulmonary angiogram was performed instead. The coroner found that had diagnostic ultrasound been immediately available, the …

cardiologyanaesthesiadiagnosticdelaypropofol
VIChospital2016-10-25

Finding into death of Andrew Michael ODonnell

46y · Male·Pulmonary thromboembolism complicating left calf deep venous thrombosis

A 46-year-old man presented to ED with a two-day history of left calf pain, swelling and numbness. He was triaged to Fast Track and evaluated by an emergency physician who suspected DVT but had no ultrasound available on…

emergency medicinehaematologydiagnosticenoxaparin
TAShospital2025-01-21

Coroner's Finding: Connlley, Maurice Gordon

76y · Male·Extensive small bowel infarction caused by superior mesenteric artery thrombus

…c ischaemia—characterised by severe pain without significant clinical signs—was not diagnosed until a CT angiogram performed 19 hours post-presentation revealed superior mesenteric artery thrombosis with acute bowel isc…

emergency medicinesurgerydiagnosticdelayanticoagulant
VIChomePodcast2018-11-09

Finding into death of Priyantha Nirmale Ranjith Peiris

57y · Male·hypoxic ischaemic brain injury complicating acute asthma

A 57-year-old man with asthma and hay fever died from hypoxic ischaemic brain injury following an acute asthma exacerbation during Melbourne's November 2016 thunderstorm asthma event. The deceased was outdoors during the…

emergency medicineintensive caresalbutamol
VIChospital2017-02-23

Finding into death of Goet Wo Tjoeng

71y · Female·aortic dissection (Stanford Type A)

…erlying cause was a Stanford Type A aortic dissection, which was not identified during life despite a CT angiogram being performed. The CT images were suboptimal due to poor cardiac output and could not adequately exclu…

cardiologyradiologydiagnosticcommunicationnoradrenaline
QLDhospital2016-06-16

Mr M - Non-inquest findings

53y · Male·Bilateral ACA stroke

…ot reviewed by the stroke team until 4:00 pm—well beyond the 4.5-hour thrombolysis window. Although a CT angiogram identified an ACA thrombus, lysis therapy was not administered. The coroner found a missed opportunity f…

emergency medicineneurologydiagnosticcommunication
QLDhospital2011-09-20

Long, Kerry-Ann

42y · Female·Subarachnoid haemorrhage as a consequence of rupture of saccular aneurysm of the…

Kerry-Ann Long, a 42-year-old woman in custody at Brisbane Women's Correctional Centre, collapsed suddenly on 3 February 2009 from rupture of a previously undiagnosed anterior communicating artery aneurysm causing subara…

emergency medicineneurosurgerymethadone

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