Coronial

14 results for low body weight

VICcommunity2025-09-30

Finding into death of Viet Quy Dinh

39y · Male·Drowning

A 39-year-old man drowned while snorkelling at Altona Beach wearing a 10.95 kg weight belt without fins or buoyancy compensation device. He became fatigued in deep, choppy water with poor visi…

QLDaged care2024-10-10

Non-inquest findings into the death of Jean Alice Dowson

79y · Female·Chronic obstructive pulmonary disease

…vide palliative care was appropriate, the approach diverged from best practice which recommends starting at lowest doses and titrating upward. The coroner found the CNC and GP erred in clinical judgment, though could no…

general practicepalliative caremedicationdiagnosticmorphine
NSWaged care2012-05-11

Inquest into the deaths of Shaneen BATTS, Ilona TAKACS, Dorothy HUDSON, Ian BIRKS, Donald MacKELLAR and Mohammed RAMZAN

Unknown·Multiple: Olanzapine toxicity, pulmonary thromboembolism, asphyxiation on food, …

…rmacy without toxicity monitoring despite critically elevated drug levels found at autopsy; (2) dangerously low body weight not considered in dosing decisions; (3) no 6-monthly blood tests for patients on long-term anti…

psychiatrygeneral practicediagnosticmedicationolanzapine
QLDcommunity2014-09-26

P, a child

11y · Female·Head injury due to quad bike accident (rollover)

…rer warnings against operation by persons under 16 years. The bike had significantly underinflated tyres (below 1psi versus recommended 3.1-3.63psi), which contributed to handling difficulties. While riding cautiously o…

systemsupervision
TAScommunity2025-10-21

Coroner's Finding: de-identified CP

22y · Female·accidental drowning

A 22-year-old woman with cerebral palsy, intellectual disability and no formal swimming training drowned at Somerset Beach, Tasmania. She was in waist-deep water with her carer and another child when a strong rip current…

NSWcommunity2024-05-03

Inquest into the death of Keith Titmuss

20y · Male·exertional heat stroke

…league player collapsed and died from exertional heat stroke after his first pre-season training session following an extended off-season break. Keith had the lowest aerobic fitness of his cohort (Yo-Yo test score 680m …

sports medicineemergency medicinesystemdelaymidazolam
VIChome2015-07-20

Finding into death of Hazel Angela Bampton

67y · Female·Pulmonary thromboembolus secondary to deep vein thrombosis in the setting of con…

…oprophylaxis for outpatients with obesity requiring limb immobilisation. Current NHMRC guidelines recommend low molecular weight heparin for hospitalised patients with cast immobilisation, but not for outpatients. Evide…

emergency medicineorthopaedic surgerysystem
SAhospital2020-01-10

Coroner's Finding: FIORETTI Louisa Jill Josephine

19y · Female·2,4-dinitrophenol toxicity

A 19-year-old woman died from 2,4-dinitrophenol (DNP) toxicity after intentionally ingesting approximately 50 x 250mg capsules purchased online. She presented to Flinders Medical Centre with an Inpatient Treatment Order …

toxicologyemergency medicine2,4-dinitrophenol
VIChospital2018-11-26

Finding into death of Sarah Hammoud

22y · Female·septic shock complicating osteomyelitis secondary to cellulitis in a woman with …

Sarah Hammoud, aged 22 with cerebral palsy and intellectual disability, died from septic shock complicating osteomyelitis secondary to cellulitis. She resided in a supported residential service and had recurrent elbow in…

general practiceorthopaedic surgerycommunicationsystemantibiotics
TAShome2025-06-24

Coroner's Finding: Infant W and Infant P

Unknown·Infant W: asphyxia due to accidental overlay by parent in unsafe sleeping enviro…

…other children), failure to provide safe sleeping education despite policy requirements, and decisions to allow discharge without protective orders. CHaPS and hospitals provided adequate safe sleeping information, but C…

paediatricspsychiatrydiagnosticcommunicationmethadone
TAScommunityPodcast2019-05-21

Coroner's Finding: Tolputt, Trevor

55y · Male·hypothermia

…cissus Hut, this critical information was not relayed to Parks and Wildlife Services or police until the following morning, delaying rescue by ~12 hours. However, expert evidence established Tolputt would have died by a…

emergency medicinepathologycommunicationsystem
VIChospital2014-11-26

Finding into death of Ming Shan Yuan

88y · Male·Tuberculous pneumonia in the setting of multiple rib fractures, osteoporosis and…

… The coroner found the rib fractures likely resulted from assault rather than accidental fall, and that his low body weight may have contributed to tuberculosis reactivation. Annie, his carer, was found to have physical…

emergency medicinegeriatric medicinediagnosticdelayantibiotics
NSWhospital2012-11-20

Channell & ivanoska decision

Female·Pulmonary thromboembolism due to deep vein thrombosis following lower leg fractu…

Two women aged 48 and 59 presented to Shellharbour Hospital ED with lower leg fractures sustained in falls. Both were treated conservatively with immobilization (splint and plaste…

emergency medicineorthopaedic surgerydiagnosticsystem
VIChome2025-11-18

Finding into death of JZA

65y · Female·Combined effects of acute pneumonia, pancreatitis, urinary tract infection, and …

…fects of pneumonia, pancreatitis, urinary tract infection, and severe pressure ulcers with osteomyelitis following a prolonged lie at home. She had been largely bedridden for years, refusing medical care and in-home sup…

geriatric medicineinfectious diseasessystemcommunicationpholcodine

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