Coronial

452 results for emergency procedures training

VICcommunity2020-11-19

Finding into death of Zachary Matthew Bryant

Unsurvivable traumatic injuries from blunt force impact with motor vehicle; pred…

…tel (33). All victims sustained unsurvivable blunt force head and multiple injuries. Despite appropriate emergency medical response including first aid, oxygen therapy, ambulance transport, emergency craniectomy, intuba…

emergency medicinetrauma surgery
VICcommunity2003-05-21

DACK Lindsay

43y · Male·Drowning

…tiple preventable failures: lack of mandatory PFD/harness wearing for deck crew; inadequate man overboard training; failure to deploy flotation devices; delayed Mayday call; helm damage reducing boat control; and propell…

systemprocedural
QLDmental health2004-09-30

Cif Lee Ja 20040930

23y · Male·compression of the neck, secondary to coronary arteriosclerosis

…cation of force. The coroner made no criminal findings but identified systemic failures: inadequate staff training in restraint procedures, no doctor physically present on the ward, unclear protocols on prone positioning…

psychiatryemergency medicineproceduralcommunicationdroperidol
NSW2015-08-14

Inquest into the death of Kathryn Anne SHEPPARD

48y · Female·head injuries in combination with the effects of fire sustained when the aircraf…

…he findings highlight the importance of proper guidance material for multi-engine aircraft operations and training regarding engine failure procedures. The coroner made recommendations to the Civil Aviation Safety Author…

NSWcommunity2010-07-02

Findingandrecommendations mcleanjulia415 08

Female·Acute Necrotising Pulmonary Disease, probably Goodpasture's Syndrome

…ring hand in rural Walgett, NSW. The coroner found no clinical error but identified gaps in occupational emergency response systems. Recommendations included disseminating emergency response and first aid information to…

occupational and environmental health
VIChome2022-04-27

Finding into death of Leonardo Antonio Biancofiore

61y · Male·Neck injuries in the setting of a dog attack

… the dog, left unsupervised, attacked him aggressively. His wife attempted rescue but was also attacked. Emergency services responded but delays occurred in the 000 call-taking and dispatch system due to concurrent seve…

emergency medicineforensic medicinesystemcommunication
WAhospital2011-11-22

Inquest into the Death of Ashdown

27y · Male·cardiac arrhythmia during restraint; mechanism involved hypoxia and asphyxiation…

…nd restraint. The coroner found the death was by misadventure but raised serious concerns about restraint training, procedural safety, and inadequate monitoring of access to alcohol and drugs that precipitated his acute …

psychiatryintensive careproceduralsystemhaloperidol
NSWcommunity2014-09-16

Inquest into the death of Michael WILSON

42y · Male·Extensive blunt trauma injuries sustained during the course of rescuing an injur…

…ing extraction in difficult terrain. The crew developed a complex rescue plan involving modified hi-line procedures and self-belay systems that deviated significantly from standard operating procedures. Critical issues i…

emergency medicineaviation medicineproceduralcommunication
TAS2024-06-27

Coroner's Finding: Corbin, Roger Paul

57y · Male·multiple injuries sustained in helicopter crash

Roger Corbin, a highly skilled and experienced helicopter pilot and instructor, died in a crash during emergency training on 7 November 2017. While instructing student John Osborne in a simulated hydraulic failure lan…

aviation medicineemergency medicineproceduralcommunication
VIC2026-03-12

Finding into death of Fan Yang

29y · Male·Drowning in the setting of flash flooding

…couple drove through floodwaters and their vehicle became submerged. Parks Victoria staff lacked specific training and procedures for severe flash flooding of this magnitude, though they responded appropriately once the …

ACTmental health2021-03-04

Inquest into the deaths of ANTHONY LEIGH BEARHAM, NICOLA JOY FISHER, CHRISTINE BELLE DOUCH andKEN ALEXANDER LUCAS

Bearham: hypoxic brain injury from hanging; Fisher: asphyxiation from hanging by…

…ing. The coroner found systemic failures including inadequate ligature risk mitigation, poor observation procedures, failure to properly search for dangerous items, inadequate staff training, and communication failures b…

psychiatryemergency medicinediagnosticsystem
QLD2009-01-27

Scholl, Philip Henry

42y · Male·multiple injuries sustained in aircraft crash resulting from port side wing tip …

Philip Scholl, an inexperienced microlight pilot with only 20 hours flight training, died in a crash near Mareeba on 20 October 2005. The aircraft T2-2776 was airworthy unfit due to degrade…

aviation medicineemergency medicinediagnosticsystem
NT2001-12-19

Inquest into the death of Johnno Wurramarba

15y · Male·compression of the neck by hanging

… (2) inadequate court representation and prosecutorial assistance at remote bush courts; (3) insufficient training of Don Dale staff in recognizing suicide risk factors and mental illness indicators; (4) inadequate menta…

paediatricspsychiatrydiagnosticproceduralcannabis
QLDcommunity2009-02-12

Malu Sara vessel - Flora Enosa, Wilfred Baira, Ethena Enosa, Ted Harry, Valerie Saub

Drowning or immersion; the precise medical cause could not be ascertained as onl…

…freeboard and inadequate buoyancy. It lacked essential navigation equipment. The skipper received minimal training on the new vessel and was lost in fog. The coroner found critical failures in vessel procurement, safety …

proceduralcommunication
NSWcommunity2021-12-23

Inquest into the deaths of Judith CHRUPALO and Christopher CLEE

73y · Female·Unknown due to decomposition

Mrs Chrupalo, a 73-year-old woman with physical disability, cognitive impairment and alcohol dependency, was discharged from Dubbo Base Hospital on 8 July 2015 against medical advice despite being bedbound and dependent …

geriatric medicinepsychiatrydiagnosticcommunication
QLDcommunity2017-11-27

Finlayson, Eric Davis

68y · Male·drowning against a background of cardiomegaly and severe coronary artery calcifi…

…ational visitor); lack of identification and control measures for at-risk snorkellers; inadequate lookout training and scanning protocols; poor group management with insufficient supervision of individual snorkellers; an…

emergency medicineoccupational and environmental healthsystemcommunication
QLDhospital2006-09-13

Rawson, Robert Donald

68y · Male·Internal haemorrhage due to coagulopathy and upper gastrointestinal varices, cir…

… acute cardiac events. The coroner recommended Queensland Health address equipment standardisation, staff training in surgical skills, procedural venue standards, and documentation practices in regional centres.

general surgeryrespiratory medicinesystemproceduralfresh frozen plasma
VICcommunity2020-05-14

Finding into death of Leonie Maree Hanson

40y · Female·Drowning

…ier while attempting to rescue a student, Logan Saminathan, who surfaced unconscious during an open water training dive. The student likely panicked underwater in severe conditions (40 km/h winds, 2-metre waves, 12°C wat…

diving medicineoccupational and environmental healthdiagnosticcommunication
NSW2015-09-21

Inquest into the death of William Crews

26y · Male·gunshot wound to the neck

…n rather than deliberate misconduct. Recommendations addressed risk assessment processes, identification procedures, communications, supervision oversight, safety officer roles, and defensive tactics training.

forensic medicineemergency medicineproceduralcommunicationcocaine
TAScommunity2022-11-11

Coroner's Finding: UR de-identified

16y · Male·drowning

…actors included: inadequate dive buddy supervision (Mr Yu was inexperienced and unaware of proper rescue procedures), no formal free-diving course training, diving while fatigued (the day after an intensive dive), and la…

communicationsystem
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