Finding into death of Edis Vytas Brenner

78y · Male·Multiorgan failure consequent upon pulmonary lacerations and haemorrhage sustain…

…erficial laceration to the right lower lobe lung occurred, likely from pleural space manipulation or chest drain placement. This resulted in severe unexpected bleeding requiring return to theatre and massive transfusion…

Finding into death of Michele Valentino

81y · Male·Head injury sustained in a fall

…d the outcome given the severe nature of bleeding and his post-operative complications including recurrent drain blockages. Key clinical lessons include: ensuring robust communication protocols for critical radiological…

Inquiry into the fire at UTS on 27 November 2012

…e. Key findings: IROFSD hydraulic suction hoses incinerated, allowing 400-600 litres of hydraulic fluid to drain into the fire and significantly increase intensity; fire extinguishers were inadequate capacity (2kg); eva…

Inquest into the Death of Herbert William MACKAY

45y · Male·complications associated with metastatic adenocarcinoma of the lung, treated pal…

…pital admissions over three months for management of recurrent pleural and pericardial effusions requiring drainage procedures. The coroner found the lung cancer presented at an advanced stage with diffuse cell growth u…

Inquest into the death of Adam Fitzpatrick

20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…

Adam Fitzpatrick, a 20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged…