Coronial

21 results for full blood examination

NSWcommunity2011-12-08

Coroner's Finding: Christine Crickitt

Female·undetermined

…or 1 January 2010 at Woodbine in unexplained and possibly suspicious circumstances. The coroner conducted a full inquest spanning eight hearing dates but could not determine either the cause or manner of death due to ins…

forensic medicinepathologysystem
VIChospital2014-07-16

Finding into death of Beverly Davidge

78y · Female·Acute gastrointestinal haemorrhage

…y), and discharged after 24 hours. She deteriorated at home on 13 November and was readmitted with ongoing blood loss despite transfusions. She became unwell on 15 November, at which point aggressive treatment was cease…

gastroenterologygeneral medicine
QLDaged care2010-08-19

Dossetto, Kate Emma

86y · Female·Unable to be determined

…rticularly given her significant pre-existing ischaemic heart disease and heart failure. However, without a full autopsy, the actual cause could not be determined. The coroner found no evidence of direct intervention. Ke…

pathologypharmacologymedicationsertraline
NSWhome2023-04-26

Inquest into the death of AX

70y · Female·Cause of death could not be determined - available evidence does not allow a fin…

…suing coroner's certificates without adequate medical investigation, and the critical need for external examinations and toxicology sampling when sudden unexpected deaths occur in potentially suspicious circumstances.

forensic medicinecardiologysystemdelaycandesartan
VIChospital2021-03-31

Finding into death of Sarah Louise Rose

40y · Female·Cerebral oedema of unknown aetiology with probable contribution from Hashimoto's…

Sarah Louise Rose, aged 40, died from cerebral oedema of unknown aetiology with probable contribution from Hashimoto's encephalopathy. She had been diagnosed with Hashimoto's thyroiditis in late 2011 and prescribed thyro…

general practiceemergency medicinediagnosticcommunicationthyroxine
VIChome2016-03-24

Finding into death of Caroline Emily Lovell

36y · Female·Global ischaemic injury following cardiorespiratory arrest in the immediate post…

…elody Bourne. Caroline remained in the birthing pool for over one hour without vital sign monitoring or examination. When she lost consciousness getting out of the pool and subsequently deteriorated with agitation and s…

midwiferyobstetricsdiagnosticcommunicationsyntocin
QLDhospital2016-02-17

Dickinson, Rick Dudley

55y · Male·Cardiac tamponade due to ruptured aortic dissection (Type A) against a backgroun…

… treating senior doctor failed to adequately assess the chest pain history, conduct appropriate cardiac examination, or order immediate imaging of the chest. Although a CT scan of the lumbar spine was performed (normal)…

emergency medicinepathologydiagnosticcommunicationmorphine
WAcommunity2021-05-10

Inquest into the Suspected Death of Jennie Anne KEHLET and the Death of Raymond Keith KEHLET

Female·Ray: homicide by a person or persons unknown involving blunt force trauma; Jenni…

…r persons unknown, with evidence showing blunt force trauma, a fractured hyoid bone, significant bleeding (blood found in boot treads indicating he stood in a pool of blood before death), and injuries inconsistent with …

forensic medicineemergency medicinediagnosticdelay
VIC2011-07-28

Finding into death of Mr M

82y · Male·closed head injury (subdural haematoma) sustained in a fall

…a urinal bottle, despite falls risk assessment identifying he needed assistance with toileting. Initial examination appeared thorough with normal vital signs and neurological findings, and CT scan was not performed. He …

emergency medicineneurosurgerysystemdelaywarfarin
SAhospital2005-06-03

Coroner's Finding: SORENSEN Ruth Bengta Maria

69y · Female·faecal peritonitis due to small bowel obstruction and perforation due to periton…

…t with abdominal pain and vomiting. The doctor did not take adequate history, perform thorough physical examination, or order basic investigations including blood tests or abdominal X-ray. She was discharged after 2 hou…

emergency medicinesurgerydiagnosticcommunicationprochlorperazine
VIChospital2013-07-29

Finding into death of Beverley Pattinson

70y · Female·Severe dehydration and renal complications secondary to intestinal obstruction d…

A 70-year-old woman presented to a rural hospital with 48 hours of vomiting and dehydration secondary to an inguinal hernia obstruction. The initial assessment by the hospital medical officer failed to adequately review …

emergency medicinegeneral practicediagnosticcommunicationmetoclopramide
VIChospital2014-03-21

Finding into death of Michelle Johnson

31y · Female·Ruptured splenic artery aneurysm with extensive retroperitoneal and intraperiton…

…sion on 21 March 2010. She was assessed by registrar Dr F. and covering specialist Dr L., with initial low blood pressure attributed to musculoskeletal pain from dancing. Investigations were unremarkable. After discharg…

obstetricsemergency medicinecommunicationsystempethidine
NSWhospitalPodcast2021-05-07

Inquest into the death of Brent Justin CROUGH

24y · Male·Complications of Brown Snake Bite

Brent Crough, a 24-year-old man, died from complications of brown snake bite in hospital. He was bitten on his right finger while separating the snake from his dog and was transported to Tamworth Base Hospital. Despite a…

emergency medicinetoxicologysystemdelaybrown snake antivenom
NSWhospital2010-05-31

Coroner's Finding: Isaraelu Pele

8y · Male·bacterial meningitis that had not been diagnosed by a number of clinicians who h…

… signs (lethargy, fever, headache, persistent vomiting, pallor), and failure to perform lumbar puncture or blood cultures. Paracetamol appeared to improve symptoms, falsely reassuring clinicians. The coroner found the d…

general practiceemergency medicinediagnosticdelayparacetamol
SAhospital2012-07-31

Coroner's Finding: KISON Trinity Isabel

0y · Female·respiratory failure due to congenital pneumonia with hyaline membrane disease ca…

Trinity Kison, a 21-hour-old neonate born at 35 weeks gestation, died from respiratory failure due to congenial pneumonia caused by streptococcus pneumoniae. The maternal high vaginal swab taken one week before delivery …

obstetricsneonatologydiagnosticcommunicationbenzylpenicillin
VIChospital2025-08-04

Finding into death of Winifred Jean Carpenter

82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…

…unicated only via text message to a group chat and not formally escalated to senior staff; and physical examination was not performed despite nursing observations of distension. The coroner found discharge was inappropr…

general surgerycolorectal surgerydiagnosticcommunication
QLDhospital2016-11-04

Neitsch, Horst - non-inquest findings

77y · Male·Stroke; cardiogenic shock; severe aortic stenosis with three vessel coronary art…

Mr Neitsch, a 77-year-old with severe aortic stenosis, peripheral vascular disease, and reduced left ventricular function, underwent elective coronary angiography at Princess Alexandra Hospital on 21 May 2015. The proced…

cardiologyvascular surgeryproceduralcommunicationfurosemide
WAcommunity2005-08-19

Inquest into the Death of Laura Kate Muckersie

20y · Female·Methylamphetamine toxicity

…avenues identified by Acting Inspector Zanetti, was dismissive of recommendations despite not accessing the full case file, and ineffectively terminated the investigation. The coroner made five recommendations to improve…

diagnosticsystemmethamphetamine
WAhospital2023-02-22

Inquest into the Death of Aishwarya Aswath CHAVITTUPARA

7y · Female·multiorgan failure due to fulminant sepsis (Streptococcus pyogenes)

…uity (category 4). Critical missed opportunities occurred: a junior doctor performed only a focused eye examination without comprehensive assessment; a junior nurse recorded abnormal vital signs (fever, tachycardia, tac…

emergency medicinepaediatricsdiagnosticcommunication
VIChospital2019-09-26

Finding into death of Tangimama Tavai

35y · Female·Unascertained

…he death. The induction was scheduled outside normal working hours when consultant staff were off-site and blood bank services were not at full capacity. Escalation pathways were unclear, and the registrar did not reque…

obstetricsanaesthesiacommunicationsystemoxytocin

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