Coronial
SAhospital2019-05-31

Coroner's Finding: CHAPLIN Gray Clyde

81y · Male·multi-organ failure complicating multiple right-sided rib fractures due to a fal…

An 81-year-old man sustained multiple rib fractures from a 1.5m ladder fall. Initial assessment at a rural hospital on day one was appropriate. Howev…

general practiceemergency medicinediagnosticdelaymorphine sulphate
VIChospital2015-02-04

Finding into death of Joan Coutts

72y · Female·Pneumonia in the setting of multiple rib fractures and chronic obstructive pulmo…

…COPD and diabetes presented to the emergency department on Good Friday with severe (9/10) right-sided chest pain from multiple rib fractures sustained in a fall. She was triaged to Category 5 (least urgent) despite sever…

emergency medicinegeneral practicediagnosticcommunication
VIChome2026-04-14

Finding into death of James Thomas Reilly

86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall

James Reilly, 86, fell at home on 8 September 2024 sustaining rib fractures that caused a fatal left haemothorax. Paramedics attended but he declined transfer. When facial d…

emergency medicinegeneral medicinediagnosticmedicationenoxaparin
VIChospital2014-04-17

Finding into death of Grazia Giosserano

61y · Female·Acute renal failure and dehydration in the setting of cirrhosis (secondary to he…

A 61-year-old woman with cirrhosis secondary to hepatitis C sustained rib and clavicle fractures in a motor vehicle collision. She was discharged from the ED after 6 hours despite h…

emergency medicinesurgerydiagnosticdelaytramadol
VIChospital2018-09-27

Finding into death of Elizabeth Mary Gorman

35y · Female·Pulmonary thromboembolus and pulmonary infarction

…at 11 weeks gestation presented to Royal Women's Hospital Emergency Care on 3 September 2012 with chest and rib pain following severe vomiting. Dr M., a junior resident working alone overnight, assessed her as musculosk…

emergency medicineobstetricsdiagnosticcommunicationoxycodone
SAhospital2005-11-10

Coroner's Finding: LAZOPOULOS Christopher

34y · Male·multi-organ failure with right-sided tension pneumothorax

A 34-year-old man with a ruptured spleen and fractured ribs presented to the Emergency Department on multiple occasions with abdominal and chest pain. He was discharg…

emergency medicineintensive carediagnosticsystem
SAhospital2015-08-27

Coroner's Finding: JONES John David

65y · Male·Multi-organ failure in a man with an ischaemic right leg treated with opioids

…tions (COPD, cardiac failure, diabetes, obesity) was admitted with pneumonia and severe ischaemic right leg pain. Opioid analgesia for the leg pain precipitated delirium, requiring Mental Health Act detention for safety.…

emergency medicinerespiratory medicineopioids
QLDaged care2024-12-10

Non-inquest findings into the death of Mr O.

79y · Male·Respiratory failure due to haemothorax and hospital-acquired pneumonia due to mu…

…—no notification to family, no GP review, no additional prevention strategies implemented despite increased pain. On 12 December, he fell from bed reaching for water and sustained rib fractures with haemothorax. Critical…

geriatric medicineemergency medicinediagnosticmedicationaspirin
VIChospital2014-11-26

Finding into death of Ming Shan Yuan

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

…n 88-year-old man with osteoporosis and cachexia, died from tuberculosis pneumonia precipitated by multiple rib fractures. He suffered elder abuse and neglect by his primary carer daughter over months before hospitaliza…

emergency medicinegeriatric medicinediagnosticdelayantibiotics
VIC2026-03-17

Finding into death of Anthony Joseph Moore

71y · Male·Complications of rib fractures, liver laceration and pneumothorax sustained in a…

Anthony Joseph Moore, 71, died from complications of rib fractures, liver laceration and pneumothorax sustained in a fall at Bundoora Park on 15 August 2025. While …

emergency medicinepalliative care
NSWhospital2015-06-24

Inquest into the death of Giovanni TRIPODI

91y · Male·The combined effects of chest injuries and old age

A 91-year-old man presented to the ED after a motor vehicle crash with chest pain. While imaging revealed abnormalities, ED staff and a junior registrar considered these to be old fractures…

emergency medicineradiologydiagnosticsystemparacetamol
TAShospital2020-08-12

Coroner's Finding: Maynard, Grant Godfrey

60y · Male·multi-organ failure due to injuries sustained in motor vehicle accident, specifi…

… motor vehicle accident at low speed. Despite chest imaging showing pleural effusion and the patient having rib pain, fractured ribs were not diagnosed. Subsequently, a haemothorax developed with associated bleeding, ci…

emergency medicinegeneral medicinediagnosticdelaydoxycycline
SAaged care2024-06-19

Coroner's Finding: Murphy, Phillip Robin

76y · Male·right lower lobe pneumonia on a background of frontotemporal dementia, chronic o…

…ntia, COPD, and osteoporosis died of right lower lobe pneumonia following multiple falls causing pelvic and rib fractures at a nursing home. He was admitted to hospital on 9 February 2022 with post-fall pain, sweating, …

geriatric medicinepalliative care
VICaged care2024-04-11

Finding into death of Irene Mary Donne

85y · Female·Complications following a fall

…nt with dementia at an aged care facility. The autopsy revealed skull fracture, extradural haemorrhage, and rib fractures leading to pneumonia. Staff responded appropriately to the incident with timely assessment and pa…

geriatric medicineemergency medicinetramadol
VIChospital2022-01-10

Finding into death of John Wilfred Warner

79y · Male·Complications of multiple injuries (operated), sustained in a motor vehicle inci…

…ive way based on his mistaken assumption. The collision caused serious injuries including spinal fractures, rib fractures and sternal fractures. The patient underwent surgery but subsequently developed bronchopneumonia,…

proceduralcommunication
TASaged care2023-01-30

Coroner's Finding: Munnings, Barry

86y · Male·pneumonia

…disease, cognitive impairment and recent pneumonia admissions fell in a nursing home bathroom and sustained rib fractures and T4 vertebral fracture. He was assessed as medium falls risk despite risk-taking behaviours an…

geriatric medicineemergency medicinediagnosticsystem
NSWhospital2016-03-17

Inquest into the death of Karl Guy MEYERS

82y · Male·complications from multiple injuries received in a motor vehicle accident

Karl Guy Meyers, 82 years old, died from complications of multiple injuries sustained in a motor vehicle accident. He developed an ileus or pseudo-colonic obstruction requiring nasogastric tube (NGT) insertion. The key c…

trauma surgeryintensive carefentanyl
WAhospital2016-12-16

Inquest into the Death of Ms DHU

22y · Female·staphylococcal septicaemia and pneumonia complicating osteomyelitis of a right 1…

… woman, died on 4 August 2014 from staphylococcal septicaemia and pneumonia complicating osteomyelitis of a rib fracture sustained in April 2014. She was detained in police custody on unpaid fines and presented twice to…

emergency medicineinfectious diseasesdiagnosticcommunicationamphetamine
NT2020-08-18

Inquest into the death of David Loader

58y · Male·carcinomatosis from unknown primary

…er of unknown primary in January 2020. He presented with multiple episodes of back, abdominal, shoulder and rib pain between July and November 2019, initially attributed to musculoskeletal causes including a prisoner-ad…

general practiceoncologysodium valporate
VIChospital2019-09-06

Finding into death of David John Farlech

48y · Male·Dilated cardiomyopathy with contributing factor of acute renal impairment

…ing in a group home, died from dilated cardiomyopathy with acute renal impairment. He presented with chest, rib cage and abdominal pain on 5 October 2018, was assessed by multiple GPs who diagnosed chest infection and p…

general practicecardiologyhyoscine butylbromide

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