Coronial

11 results for primary survey

NTcommunity2006-06-29

Inquest into the death of Clifford Brown

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

…tures—injuries that were potentially survivable with appropriate treatment—Nurse Paulus failed to conduct primary and secondary surveys, did not take vital signs, and agreed to transport the deceased to his remote camp …

emergency medicineparamedicinediagnosticcommunication
VIC2012-02-15

Finding into death of Manabu Kondo

38y · Male·Multiple injuries sustained in a jet dragster accident

…o halt testing after vibration was reported on day 2. While Kondo struck his helmet on the roll cage, the primary cause was mechanical defect. The coroner found multiple cumulative oversights were dangerous and that a p…

diagnosticprocedural
VIChospital2019-07-04

Finding into death of Israel Bodean Brenssell-Rimene

0y · Male·unascertained

…, the medical cause of death remains unascertained, though aspiration of gastric contents was excluded as primary cause. The coroner found the injuries were not accidental but deliberately inflicted, likely by the recen…

paediatricsemergency medicinesystemmethamphetamine
VICpolice2017-04-10

Finding into death of Michael John Darmody

51y · Male·Combined drug toxicity (methadone and benzodiazepines) in a man with coronary an…

…, lack of communication tools like ISBAR, and failure to apply basic nursing assessment frameworks (DRABC/primary survey).

emergency medicineintensive carecommunicationdiagnosticmethadone
WA2012

Inquest into the Death of Christmas Island Tragedy

27y · Female·Immersion (drowning) and injuries from impact with rocky shore and debris in the…

…sland itself. The Commonwealth had failed to provide suitable vessels to the AFP and VMRS—both were out of survey, unsafe, and unfit for bad weather operations. Critical systemic failures included absent surveillance cap…

systemdelay
WAcommunity2025-07-02

Inquest into the Death of Donald Joseph Hemara WARD

50y · Male·Multiple injuries sustained in high-speed motorcycle crash

Donald Ward, aged 50, died from multiple injuries sustained in a high-speed motorcycle crash on 4 March 2023 in Karratha, WA. Ward left a nightclub intoxicated with alcohol (BAC 0.186%) and cannabis, obscured his number …

paramedicineemergency medicinepossibly diagnosticalcohol
WA2012-02-23

Inquest into the Deaths of SIEV 221 Victims (Christmas Island)

Drowning from immersion in the sea; for those whose bodies were not recovered, d…

SIEV 221, a fishing vessel carrying 92 people, sank on Christmas Island on 15 December 2010, killing 50 asylum seekers and crew. Thirty bodies were recovered; 20 remain missing. The vessel lacked adequate lifejackets, sa…

systemdelay
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…

This inquest examined the loss of the Malu Sara, an immigration vessel that disappeared in October 2005 with five people aboard in the Torres Strait. The custom-built vessel had serious design flaws including negative fr…

proceduralcommunication
QLDcommunity2015-08-03

Inquest into nine (9) deaths caused by Quad Bike accidents

Multiple causes across nine deaths; primary causes included rollover with crush …

This is a complex coronial inquest examining nine quad bike deaths in Queensland, with a focus on prevention through regulatory and design measures. Key clinical and safety lessons include: (1) helmet use is critical—33.…

systemdelay
SAhome2014-09-05

Coroner's Finding: HARRISON Noah Alexander Edward

0y · Male·unascertained; possibly asphyxiation related to sleeping position

Noah Harrison, aged 12 weeks, died of unascertained cause in October 2010. He was found face-down in a pram with unsafe sleeping arrangements. At prior hospital admission on 17 September 2010 for fever and reported haema…

emergency medicinepaediatricsdiagnosticcommunication
WAhospital2024-05-23

Inquest into the Death of Baby BE (Name Subject to Suppression Order)

0y · Female·brain death complicating head and neck injury

A five-month-old girl died from catastrophic brain injuries caused by violent shaking on 20 May 2019. Medical evidence established she was shaken by an adult on at least two occasions: once around 6 May 2019 (evidenced b…

paediatricsneonatologydiagnosticcommunicationmethamphetamine

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