Coronial

14 results for intravenous access and fluid administration

QLDhospital2018-05-04

LM - Non-inquest findings

1y · Female·Sepsis (Group A Streptococcus)

…ultiple times by different GPs in the preceding weeks with viral upper respiratory tract infection symptoms and chronic impetigo. Although GP management was deemed appropriate by independent review, critical delays occu…

general practiceemergency medicinediagnosticdelaymupirocin
SAhospital2017-04-19

Coroner's Finding: ADAMSON Jean Anne

78y · Female·aspiration on a background of psychogenic dysphagia, intellectual impairment and…

…e Adamson, aged 78, died from aspiration on a background of psychogenic dysphagia, intellectual impairment, and chronic schizophrenia. She had experienced a swallowing phobia that recurred in September 2014, leading to …

general medicinepsychiatrymorphine
WAhospital2009-09-11

Inquest into the Death of Gordon

1y · Female·pneumonia (staphylococcal pneumonia with bilateral bacterial pneumonia)

Jezelle Lisa Gordon, a 1-year-old child, died of staphylococcal pneumonia on 26 February 2006 in Port Hedland, Western Australia. She presented to Halls Creek Hospital on 25 February with fever, elevated respiratory r…

general practiceemergency medicinediagnosticdelayparacetamol
NSWhospital2020-03-17

Inquest into the death of Esteban FRANCO-GARCES

11y · Male·Sepsis

An 11-week-old premature infant presented to the ED with fever, lethargy and poor feeding. Despite initial suspicion of sepsis at 1:15pm, antibiotics were not administered until 4pm—a …

emergency medicinepaediatricsdiagnosticdelayantibiotics
TAShospital2018-03-26

Coroner's Finding: Russell; Patricia Joy

74y · Female·empyema/sepsis complicating oesophageal perforation following a complicated elec…

Mrs Russell, a 74-year-old woman with diabetes, obesity, COPD and coronary disease, underwent elective hernia repair in November 2016 at a regional hospital. An unexpected c…

surgeryanaesthesiadiagnosticdelay
NTcommunity2006-06-29

Inquest into the death of Clifford Brown

58y · Male·Multiple injuries occasioned in a motor vehicle accident (broken neck, ruptured …

…on 18 December 2004 at Barrow Creek, NT. The central clinical issue was the inadequate emergency assessment and management by Registered Nurse Ann Paulus at the accident scene. Despite suffering a broken neck, ruptured …

emergency medicineparamedicinediagnosticcommunication
QLDhome2010-06-09

Muller, Bradley John

45y · Male·overdose of quetiapine (Seroquel) augmented by alcohol

A 45-year-old man with schizophrenia and a decade-long history of repeated overdoses died from quetiapine (Seroquel) toxicity combined with alcohol.…

general practiceemergency medicinecommunicationsystemquetiapine
ACThospital2018-04-26

AN INQUEST INTO THE DEATH OFJOHN BELL

71y · Male·cardiac arrest due to hyperkalemia due to acute on chronic renal failure, with r…

John Bell, a 71-year-old man with history of bowel cancer, ischaemic heart disease, and chronic renal failure, underwent elective ileostomy reversal surgery. He died from cardiac arrest due to hy…

surgerynephrologydiagnosticsystem
QLD2017-08-04

Mrs H - Non-inquest findings

76y · Female·Acute renal failure due to dehydration due to upper gastrointestinal bleed

… the district hospital for testing until 3 April, delaying results by 8 days. Dr D failed to follow up outstanding blood results upon returning to work on 5 April, despite a junior doctor clearly documenting this need. …

general medicinegastroenterologydiagnosticcommunicationibuprofen
VIChospitalPodcast2026-02-20

Finding into death of James Harilaos Tsindos

17y · Male·Hypoxic Ischaemic Encephalopathy Complicating Anaphylaxis

James Tsindos, a 17-year-old with known nut allergy and mild asthma, experienced anaphylaxis after inadvertently ingesting cashews in a vegan restaurant meal on 27…

emergency medicineallergy and immunologydiagnosticcommunicationadrenaline (epinephrine) intramuscular
WAhospital2021-11-29

Inquest into the Death of Miss T (Name Subject to Suppression Order)

16y · Female·acute abdominal obstruction secondary to adhesions associated with severe pelvic…

…c inflammatory disease caused by untreated gonorrhoea. Miss T presented to the ED twice with abdominal pain and vomiting. After her second presentation on 24 December, she was discharged home without a clear diagnosis d…

emergency medicinegeneral practicediagnosticsystemcannabis
SAhospital2017-04-07

Coroner's Finding: MAYELL Edward John

83y · Male·pneumonia and severe acute respiratory distress syndrome caused by Legionella ba…

An 83-year-old man died from pneumonia and respiratory distress caused by Legionella bacterium. He presented with abdominal symptoms and was initially…

emergency medicinegeneral practicediagnosticmedicationceftriaxone
NSWhospital2022-12-08

Inquest into the death of Austin Facer

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

…ding suboptimal initial NETS communication, MedSTAR's unjustified shift away from the agreed Adelaide plan, and inefficient multidisciplinary coordination; (2) the importance of rapid confirmation of ventricular fibrill…

paediatricsemergency medicinecommunicationsystemadrenaline
NSW2019-11-08

Inquest into the death of six patrons of NSW music festivals

Unknown·MDMA toxicity (3,4-methylenedioxymethylamphetamine toxicity) in each case

Six young people died at NSW music festivals between December 2017 and January 2019 after consuming MDMA (ecstasy) at toxic levels. Nathan Tran (18), Diana Nguyen (21), Joseph Ph…

emergency medicinetoxicologycommunicationsystemMDMA

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