Coronial

553 results for emergency transfer

TAShospital2018-10-17

Coroner's Finding: Jones, Tristan Adam

40y · Male·Subarachnoid haemorrhage due to ruptured right middle cerebral artery aneurysm

…ebral artery aneurysm on CT imaging at 8:42pm. He collapsed in the waiting room and was intubated. Urgent transfer to neurosurgery was arranged, but the Royal Hobart Hospital ICU rejected him based on bed availability ra…

emergency medicineneurosurgerysystemcommunicationparacetamol
WAhospital2020-12-01

Inquest into the Death of Tahlia Rose BEMBRIDGE

4y · Female·volvulus of the large intestine

…oration (progressive tachycardia, abdominal tenderness, lactic acidosis), she was managed conservatively. Transfer to PMH was arranged at 4.00 pm when coffee-ground vomiting and increased tenderness developed. During RFD…

paediatricsemergency medicinecommunicationdelay
NSWhospital2017-12-22

Inquest into the death of Colin Parker

41y · Male·Complications of blunt force injuries of the head

…ning adequate history and neurological assessment in ED; (2) clinical handover between cardiologists; (3) transfer arrangements to Liverpool Hospital's neurosurgery unit. Surgery eventually occurred 5+ hours after CT res…

cardiologyemergency medicinediagnosticcommunicationenoxaparin
SA2005-04-11

Coroner's Finding: POTTER Claire Elizabeth

26y · Female·multiple injuries sustained as a result of being struck by a motor vehicle on th…

…uate psychiatric assessment and monitoring at the Royal Adelaide Hospital between admission (5 March) and transfer (7 March)—only a brief confirmation review occurred over 24+ hours; (2) transfer authorised without perso…

psychiatryemergency medicinecommunicationsystemolanzapine
NSWcommunity2020-03-25

Inquest into the death of Tory GANDERTON

3y · Male·respiratory failure, with spinal muscular atrophy an antecedent cause

…year-old boy with spinal muscular atrophy (SMA) Type 1, died of respiratory failure during inter-hospital transfer. Admitted to Shoalhaven Hospital on 7 September 2014 with pneumonia and severe malnutrition (50% weight l…

paediatricsneurologycommunicationsystemadrenaline
WAhospital2020-08-13

Inquest into the Death of Susan Jessica Elsie WINDIE

22y · Female·bowel obstruction due to faecal impaction

…m Sir Charles Gairdner Hospital (SCGH). By 28 October, despite worsening pain and clinical deterioration, transfer was not arranged until 28 October evening when her condition became critical. The coroner found the proce…

gastroenterologygeneral practicecommunicationsystemfleet enema
QLDrural hospital2020-05-08

FD - Non-inquest findings

68y · Female·Sepsis (Enterobacter cloacae) due to peritonitis as a consequence of leaking per…

…lication guidance in rural settings; delayed surgical team acceptance (insisted on formal CT report); and transfer by single paramedic with nurse escort without RSQ consultation despite clinical instability. She arrested…

gastroenterologyemergency medicinediagnosticcommunicationaugmentin duo
NSWhospital2025-02-17

Inquest into the death of IE

27y · Male·Multiple blunt force injuries from jumping off a cliff

A 27-year-old involuntary mental health patient absconded from a hospital transfer vehicle and subsequently died by jumping from a cliff. Critical failures included: absence of clinical as…

psychiatryemergency medicinediagnosticcommunicationvenlafaxine
QLDhospital2025-10-01

Non-inquest findings into the death of Mr S

26y · Male·Multi-organ failure due to pneumococcal septic shock

…psis pathway. This review did not occur, causing approximately 3-hour delay in antibiotic administration. Transfer to tertiary hospital was further delayed by 5 hours due to system issues with inter-hospital transfer acc…

emergency medicineinfectious diseasesdiagnosticdelayantacid
WAhospital2013-11-08

Inquest into the Death of Nielson, Melissa Ann

24y · Female·hypoxic brain injury following unexplained cardiorespiratory arrest

…blistering rash on 3 September 2009. Dr C. appropriately identified a potentially serious dermatological emergency and arranged urgent transfer to Royal Perth Hospital (RPH), which had dermatology expertise and knowledg…

emergency medicinedermatologycommunicationdiagnosticcefalexin
SAhospital2003-05-08

Coroner's Finding: PRATT Shirley May

66y · Female·acute necrotising haemorrhagic mediastinitis

…orated oesophagus was considered but Mrs Pratt was kept at the small rural hospital overnight rather than transferred urgently to the Royal Adelaide Hospital. Transfer occurred next morning but by then mediastinitis had …

surgerygeneral surgerycommunicationsystemfentanyl
VIC2020-12-09

Finding into death of Alma Lynette Honeychurch

76y · Female·Ludwig's angina

… to urgent care with facial swelling and fever. She was appropriately diagnosed and arrangements made for transfer to a tertiary centre. However, staff failed to recognise the risk of rapid airway compromise despite docu…

emergency medicinedentistrydiagnosticcommunicationantibiotics
TAShospital2019-10-17

Coroner's Finding: Davies, Eva Fay

87y · Female·left frontal temporal subdural haematoma following closed head injury sustained …

…atoma. The neurosurgical registrar advised observation with repeat imaging in 24 hours rather than urgent transfer. The coroner found this advice incorrect: anticoagulated patients with acute subdural haematoma require u…

neurosurgeryemergency medicinecommunicationdiagnostic
NSWhospital2022-12-08

Inquest into the death of Austin Facer

6y · Male·cardiopulmonary arrest on a background of earlier cardiac arrests and resuscitat…

…ltiple cardiac arrests at school on 21 October 2019, initially resuscitated successfully, but died during transfer preparation to a higher-level hospital that evening. Autopsy revealed a coronary anomaly (anomalous aorti…

paediatricsemergency medicinecommunicationsystemadrenaline
QLDhospital2024-06-21

Non-inquest findings into the death of Mr K

81y · Male·Chronic lung disease (severe COPD) with atherosclerotic cardiovascular and valvu…

An 81-year-old man with severe COPD died following inappropriate interhospital transfer to a private hospital and subsequent management errors. Key clinical lessons: (1) patients with CO2 reten…

respiratory medicineemergency medicinemedicationcommunicationdiazepam
VIChospital2013-05-10

Finding into death of Joseph Thurgood Gates

0y · Male·Global cerebral hypoxic injury and perinatal asphyxia secondary to uterine ruptu…

…nan failed to clearly articulate risks, supported home birth plans despite clinical concerns, and delayed transfer to hospital when foetal bradycardia developed during labour. The bradycardia persisted for over 40 minute…

obstetricsmidwiferydiagnosticcommunication
VIC2025-07-04

Finding into death of Brent Reker

35y · Male·Hanging

…anging in Forbes Unit at Ravenhall Corrections Centre on 12 December 2019, approximately 90 minutes after transfer from Moroka therapeutic unit. Critical failures included: (1) his detailed suicide and self-harm (SASH) h…

psychiatryemergency medicinecommunicationsystemmethadone
NTmental health2016-07-11

Inquest into the death of Dean Jigili

23y · Male·self-inflicted hanging

…admissions and medication management, he remained symptomatic with ongoing command hallucinations. He was transferred from the secure Joan Ridley Unit to the less-secure Cowdy Ward on the same day he absconded. The coron…

psychiatryemergency medicinecommunicationsystemcannabis
NSWhospital2023-08-21

Inquest into the death of Maureen Smith

75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis

…s pending joint aspiration at Armidale Rural Referral Hospital. However, critical delays occurred: a non-emergency transport booking was made, then transferred to NSW Ambulance around 3.15pm. At 5.07pm, ambulance crew d…

orthopaedic surgeryemergency medicinediagnosticcommunicationcorticosteroid injections
VIChospital2011-07-29

Finding into death of Marlene Kenny

64y · Female·Bilateral pulmonary embolism with left middle cerebral artery/posterior cerebral…

…al stroke caused by a patent foramen ovale allowing a blood clot to cross from right to left circulation. Transfer to tertiary care was delayed over 9 hours due to poor communication between hospital and ambulance servic…

emergency medicinegeneral practicediagnosticcommunicationdiazepam
1228

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