Coronial

30 results for spinal imaging

TAShospital2019-07-25

Coroner's Finding: Horcicka, Josef Vratislav

89y · Male·fractured cervical spine (C5 inferior articular process fracture) due to unwitne…

…with Parkinson's disease fell at home on 16 August 2016, sustaining a cervical spine fracture. Initial CT imaging missed the C5 inferior articular process fracture, reporting only a paraspinal haematoma. Conservative ma…

orthopaedic surgeryemergency medicinediagnosticproceduralmorphine
VIChospital2023-07-19

Finding into death of Daryl William Nioa

74y · Male·Pulmonary thromboembolism secondary to deep vein thrombosis in the setting of re…

…74-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis following a cervical spinal fracture. He presented to rural ED with mental health concerns, was restrained by security guards after br…

emergency medicineneurosurgerydiagnosticdelayclonazepam
VIChospital2022-10-18

Finding into death of Warren Douglas Frazer

45y · Male·Complications of VATS procedure for locally advanced right upper lobe lung adeno…

…complete tumour resection or vertebral body excision, chose to remove part of the vertebra. Post-operative spinal cord compression from haematoma required emergency laminectomy, but an 8-hour delay may have worsened neur…

cardiothoracic surgeryneurosurgerydiagnosticdelay
QLDhospital2017-10-17

SWK - Non inquest findings

78y · Female·multi-organ failure due to haemorrhage into the abdomen, pelvis and retroperiton…

…ndary to intra-abdominal and retroperitoneal haemorrhage following extensive anterior and posterior lumbar spinal fusion surgery. The patient had multiple comorbidities, previous spinal surgery with persistent pain, oste…

spinal surgeryorthopaedic surgeryproceduraldiagnosticaramine
QLDPodcast2020-01-24

Willersdorf, Maria

87y · Female·Hypoxic-ischaemic encephalopathy secondary to cardiac arrest, with valvular hear…

…a CT-guided epidural injection at a private radiology clinic. Although she had undergone the procedure for spinal pain, the radiologist performed an epidural injection at the T12 level rather than the requested facet joi…

radiologypain medicinediagnosticproceduralbupivacaine
VIChospital2025-05-20

Finding into death of Michael Philip Young

67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…

Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and present…

emergency medicineintensive carediagnosticproceduralhydromorphone
QLDhospital2020-05-25

Newstead, Mark Graham

51y · Male·metastatic small round cell malignancy (Ewing's Sarcoma)

… in custody. He presented with urinary retention and lower limb weakness in January 2018, underwent urgent spinal decompression surgery, and was subsequently diagnosed with advanced metastatic cancer. Palliative care was…

orthopaedic surgeryspinal surgery
TAShospital2014-09-19

Coroner's Finding: Tetley, Barry Lindsay

72y · Male·sepsis of undetermined source (pneumonia or spinal epidural abscess)

…eing rechecked or documented, without examination by the discharging doctor, and without septic workup or imaging. Hours later he collapsed with septic shock and died despite ICU admission. The coroner found sepsis (lik…

emergency medicineintensive carediagnosticcommunication
WAcommunity2024-07-19

Inquest into the Death of Trevor Henry Albert McDONALD

83y · Male·unascertained; most likely exposure while prospecting

Trevor Henry Albert McDonald, an 83-year-old man with spinal stenosis, high blood pressure, cardiac arrhythmia, and recent hip replacement, disappeared while prospecti…

VIChospital2025-09-30

Finding into death of Robert Thoai Dao

73y · Male·Complications of cervical fractures and spinal injury (operated), sustained in a…

…r cancer) slipped on wet tiles outside McDonald's and sustained cervical and thoracic spine fractures with spinal cord injury. Attending paramedics failed to follow Ambulance Victoria spinal injury guidelines, treating i…

paramedicineemergency medicinediagnosticprocedural
QLDhospital2017-05-24

PG - Non-inquest findings

75y · Male·left retroperitoneal haemorrhage associated with lumbar spine surgery

…able spine, suggesting a simpler laminectomy would have sufficed. The coroner found that while earlier CT imaging on post-operative day 4 might have identified the haemorrhage sooner, the standard of care was not breach…

neurosurgeryintensive carediagnosticdelayheparin
WAcommunity2019-01-29

Inquest into the Death of Glenn William STRICKLAND

43y · Male·Complications of neck injury; specifically extensive brainstem infarction second…

…Strickland, an experienced Harley Davidson rider, died from brainstem infarction following severe cervical spinal injury sustained in a motorcycle crash on Julimar Road, Western Australia. He failed to negotiate a tighte…

emergency medicinetrauma surgerysystemdelay
VIChospital2023-11-02

Finding into death of Renato Ettore Poletti

72y · Male·Upper cervical spine injury sustained in a fall from a ladder

…der during home garden maintenance, sustaining a severe upper cervical spine injury (C2 fracture with high spinal cord haemorrhage) that was deemed non-survivable. He died 2 days later in ICU after palliative care. The c…

trauma surgeryneurosurgerymidazolam
VIChospital2020-07-02

Finding into death of Craig Vincent Douthie

52y · Male·C2, C3, C4 spinal injury sustained from a fall secondary to seizures

A 52-year-old man with cerebral palsy, epilepsy, and intellectual disability living in disability accommodation fell in the bathroom after a seizure and sustained cervical spine fractures (C2-C3-C4). He was admitted to h…

emergency medicineneurosurgerydelaycommunicationlevetiracetam
VIChospital2010-04-16

Finding into death of Kum Yeo Bae

60y · Female·Penetrating injury of the descending thoracic aorta complicating spinal stabiliz…

A 60-year-old woman died from a penetrating injury to the descending thoracic aorta sustained during spinal stabilisation surgery for a T12 burst fracture. During pedicle cannulation, the surgical awl fractured the…

neurosurgeryanaesthesiacommunicationdelay
QLDhospital2010-10-29

Spence, Samantha Rose

12y · Female·Raised intracranial pressure due to acute-on-chronic hydrocephalus in the contex…

Samantha Rose Spence, 12 years old, died two days after spinal fusion surgery for severe scoliosis. She had a pre-existing, asymptomatic Chiari type 1 malformation detec…

orthopaedic surgeryneurologydiagnosticcommunicationmorphine
VIC2024-12-16

Finding into death of Caroline Monique Hall

52y · Female·Spinal injuries sustained in falls in a woman with multiple medical comorbiditie…

…pilepsy, schizophrenia, and multiple comorbidities living in supported disability accommodation, died from spinal injuries sustained in falls. She fell in her bedroom on the afternoon of 7 May 2021 and appeared relativel…

general practiceemergency medicinediagnosticdelaymorphine
TAShospital2021-11-29

Coroner's Finding: Helen Mary Badcock

77y · Female·haemoperitoneum and retroperitoneal haematoma secondary to Type I aortic dissect…

…8% probability of dissection) and absence of documented cardiovascular examination. Early recognition and imaging (CT angiography) with urgent cardiothoracic surgery could have been life-saving.

emergency medicinecardiothoracic surgerydiagnosticcommunication
VIChospital2024-04-11

Finding into death of Mark Andrew Spillane

58y · Male·Septic shock secondary to intra-abdominal collections as sequelae of osteomyelit…

…sed by osteomyelitis/discitis of the spine. He initially presented with a foot bone infection detected on imaging in May 2023. Subsequent imaging revealed large bilateral psoas and retroperitoneal collections with L5/S1…

infectious diseasesgeneral medicine
TAShospital2019-10-29

Coroner's Finding: Holmes, Julie Anne

71y · Female·pneumonia following cervical spine fracture sustained in motor vehicle collision

…elow acceptable standard. Prevention required adherence to existing cervical spine protocols, appropriate imaging in elderly trauma patients, and proper clinical correlation with imaging findings.

emergency medicinegeneral surgerydiagnosticprocedural

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