Coronial

95 results for clinical instability

VIC2023-06-14

Finding into death of Robert Arthur Selby Lowe

84y · Male·Urinary tract infection in a man with Parkinson's disease

…onfusion; antibiotics were commenced. The following morning, a locum medical officer noted haemodynamic instability and recommended hospital transfer, but this was not acted upon. However, following intravenous fluid ad…

general practiceinfectious diseasescommunicationdelaycefalexin
TAShospital2025-06-17

Coroner's Finding: de-identified RS

68y · Male·Exsanguination due to peptic ulcer of the duodenum with erosion into the gastrod…

…d characteristic pattern of bleeding that stops then recurs. They should have assessed for haemodynamic instability and undertaken further investigations before discharge. The patient died that afternoon from exsanguina…

emergency medicinegastroenterologydiagnosticdelay
VIChome2025-02-07

Finding into death of T

15y · Male·Combined heroin and methamphetamine toxicity

…combined heroin and methamphetamine toxicity on 24 November 2019. He had experienced multiple placement instability (over 20 placements in two years), early trauma, parental substance use history, and escalating mental …

paediatricspsychiatrycommunicationsystemheroin
SA2014-08-13

Coroner's Finding: O'DONOHOE Troy

32y · Male·Self-inflicted gunshot wound to head

…ve triggered careful reassessment given his documented alcohol-related behaviour and apparent emotional instability. The key clinical lesson is that drink-driving offences, particularly those with significantly elevated…

system
NSW2016-07-15

Inquest into the death of Sheila Drysdale

75y · Female·hypovolaemic shock following uncontrolled blood loss from mini-liposuction stem …

…ly despite their documented use; inadequate pre-operative assessment; failure to recognise haemodynamic instability (dropping blood pressure, rising heart rate); premature discharge rather than emergency hospital admiss…

plastic and reconstructive surgerygeriatric medicinemedicationproceduralaspirin
SAhospital2016-09-01

Coroner's Finding: CORBO Antonio

90y · Male·bowel obstruction leading to acute renal failure, sepsis and respiratory failure

…c and respiratory issues. He presented to hospital with coffee-ground vomiting and severe abdominal pain. Clinical examination revealed critical illness with haemodynamic instability, hypoxia, peritonism, and imaging con…

emergency medicinegeriatric medicine
WAcommunity2022-08-17

Inquest into the Death of Quoc Xuan TRAN

36y · Male·Immersion (drowning)

…er on 10 April 2019. He was subject to a Community Treatment Order and had experienced repeated housing instability over 30 months, being evicted five times. Despite proactive case management efforts to secure appropria…

psychiatryemergency medicinesystempaliperidone
TAShome2023-12-14

Coroner's Finding: Drummond, Samuel Patrick

44y · Male·acute alcohol intoxication

…A postmortem revealed fatty liver and cardiomegaly. While this death was not preventable in the immediate clinical sense, it underscores the challenges of treating alcohol use disorder, the importance of sustained addict…

toxicologypathologyalcohol
NSWhome2020-11-06

Inquest into the death of Bosco Toufalous

35y · Male·Combined effects of positional asphyxiation and intoxication

…ired his ability to protect his airway and reposition himself. Pre-existing knee injuries amplified his instability. No evidence supported assault. Clinical lessons include recognizing that severe alcohol intoxication i…

forensic medicinetoxicologyalcohol
VIChospital2015-04-23

Finding into death of Grant Phillip Scheibner

62y · Male·Pneumonia in a man with multiple comorbidities

…reassessed as pre-terminal on 16 September and transitioned to comfort care. He died on 18 September. The clinical lesson is the importance of recognising early clinical deterioration, particularly increased respiratory …

general medicinerespiratory medicine
VIChome2021-06-29

Finding into death of JM

42y · Male·Mechanical asphyxia in setting of external compression of chest by ride on mower

…fter his ride-on lawnmower rolled over a retaining wall on a slope exceeding recommended angles. Critical clinical lessons: the seatbelt with rollover protection system (ROPS) was equipped but not worn—wearing it would l…

VIC2011-12-02

Finding into death of Garry John Stephens

46y · Male·Ventricular arrhythmia in a man with epilepsy and documented episodes of bradyca…

…a episodes. The coroner accepted this as consistent with sudden unexpected death in epilepsy (SUDEP). Key clinical lessons: SUDEP is a recognised but unpredictable complication of epilepsy with no proven prevention strat…

psychiatryneurologycommunicationsystemphenytoin
SAhome2025-03-31

Coroner's Finding: Tanti, Greg Anthony

43y · Male·compression of the neck in keeping with hanging

…oner found hospital care and correctional services supervision were appropriate in the circumstances. Key clinical lessons include: the importance of checking drug levels when overdose is suspected despite patient denial…

emergency medicinepsychiatrysodium valproate
WAcommunity2020-06-03

Inquest into the Suspected Death of Anthony JOHNSTONE

33y · Male·Exposure to the elements whilst in a mentally unstable state; manner of death Op…

… while evading contact due to his mental disturbance. No remains were ever found. The case highlights the clinical challenges of managing acute delirium/psychosis in remote communities where vulnerable individuals may fl…

alcohol
NThospital2011-09-09

Inquest into the death of Linda Nha Tran

34y · Female·Catastrophic post-partum haemorrhage following caesarean delivery, secondary to …

…g hysterectomy and ICU admission. She developed multi-organ failure with irreversible shock and died. Key clinical lessons: ensure clear communication between surgical and anaesthetic teams during obstetric emergencies; …

obstetricsanaesthesiamedicationcommunicationoxytocin
QLDcommunity, community, community2019-08-30

Nebauer, Talieha; Fowell, William and Whiticker, Caitlin Wilkinson

18y · Female, female, male·Caitlin: suicide by hanging; Talieha: suicide by hanging; William: suicide by tr…

…th whom she had a dysfunctional relationship, medication non-compliance (particularly lithium), housing instability, and recent relationship breakdown. Talieha had post-traumatic stress disorder and borderline personali…

psychiatrypsychologycommunicationsystem
VICcommunity2024-10-04

Finding into death of T K

18y · Female·Mixed drug toxicity

… overdose. She had multiple psychiatric admissions in early 2021 for suicidal crises. Despite appropriate clinical care during hospitalizations, she was discharged to inadequate accommodation (hotels) with limited outrea…

psychiatrygeneral practicesystemdelaytramadol
QLDhome2008-04-10

Bond, Jakai Ryan

0y · Male·Positional asphyxia contributed to by bronchopneumonia and head injuries

…g the baby in a lounge chair; the infant was found face down on his father's lap at approximately 4:00am. Clinical lessons include: infants in the care of fatigued or substance-affected adults are at significant risk; a …

paediatricsforensic medicinedelaycannabis
WAhome2021-12-15

Inquest into the Death of Child J (Name Subject to Suppression Order)

15y · Male·ligature compression of the neck (hanging)

…th highlights systemic issues in remote out-of-home care: staff attrition, resource scarcity, placement instability, and the profound effects of early trauma and FASD on emotional regulation and impulse control. Prevent…

psychiatrypaediatricssystemdelay
TAShome2019-04-24

Coroner's Finding: Porteous, Shayne Edward

59y · Male·mixed drug toxicity (tramadol and sertraline), likely serotonin syndrome

… daily), exceeding safe guidelines. When his sertraline was increased from 100mg to 150mg for emotional instability—symptoms potentially representing early serotonin toxicity—the combined high-dose serotonergic agents c…

general practicepharmacymedicationcommunicationtramadol

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