Coronial
QLDhospital2016-06-16

Mr M - Non-inquest findings

53y · Male·Bilateral ACA stroke

A 53-year-old man presented to the emergency department with acute stroke symptoms (left-sided hemiplegia and dysphasia) with onset around 10:30 am. Due to fluctuating symptoms and…

emergency medicineneurologydiagnosticcommunication
VIChome2018-10-03

Finding into death of Yvonne Rose Vizard

72y · Female·Obstruction of the airways of the neck

…man with moderate-severe expressive and receptive dysphasia following an acute left middle cerebral artery stroke died by hanging three months post-discharge from rehabilitation. Critical deficiencies were identified in …

neurologyrehabilitation medicinediagnosticsystem
QLDhospital2025-07-15

Inquest into the death of Errol George Radan

83y · Male·left middle cerebral artery cerebrovascular accident

An 83-year-old male prisoner died from a left middle cerebral artery stroke on 26 October 2022, seven days after presenting with acute stroke symptoms. Mr Radan had atrial fibrillati…

neurologyemergency medicinedabigatran
QLDhospital2026-03-06

Non-inquest findings into the death of Ms B

35y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to vertebro…

…nitial assessment inadequate: the senior medical officer failed to recognise classic posterior circulation stroke signs documented by paramedics, did not contact a stroke specialist, and inappropriately attributed sympto…

emergency medicinegeneral practicediagnosticcommunication
VIChomeNew2026-06-10

Finding into death of Laura Claire Brady

41y · Female·Aspiration pneumonia complicating an ischaemic stroke in a woman with epilepsy, …

…ransported her to hospital where investigations revealed a subacute right middle cerebral artery ischaemic stroke and pneumonia with sepsis. She was appropriately admitted to the Neurology Department, where she received …

neurologyemergency medicine
VICaged care2012-09-18

Finding into death of Brian Lench

58y · Male·Aspiration pneumonia in a man with a left middle cerebral artery stroke (palliat…

…-year-old man with intellectual disability in DHS residential care, suffered a left middle cerebral artery stroke on 6 October 2011. He developed aspiration pneumonia complicated by acute respiratory distress syndrome, d…

emergency medicineneurologyantibiotics
VICaged care2016-06-14

Finding into death of Wendy Maree Jones

51y · Female·Bronchopneumonia and cerebral infarction in a woman with cerebral palsy

A 51-year-old woman with cerebral palsy, epilepsy, and swallowing difficulties suffered a stroke on 10 July 2015, presenting with right-sided facial droop and hemiparesis. Initial investigations at North…

neurologyemergency medicinemorphine
NSWcommunity2023-07-25

Inquest into the death of Malcolm McPhail

82y · Male·unknown

…e had early signs of dementia, prior episodes of becoming lost, was blind in one eye, and had a history of stroke. Despite extensive multi-agency search and rescue efforts over several days involving police, SES, RFS, an…

SA2016-08-04

Coroner's Finding: REED William Matthew

45y · Male·aspiration pneumonia secondary to left middle cerebral artery infarct complicate…

William Matthew Reed, aged 45, a remanded prisoner, suffered a large left-sided middle cerebral artery stroke on 21 August 2013 at the Adelaide Remand Centre. His cellmate recognised stroke symptoms at approximately …

neurologyintensive caremethadone
WAhome2025-07-11

Inquest into the Death of Monique Jacinta GOMEZ

48y · Female·intracerebral haemorrhage on a background of anticoagulation therapy for a recen…

Monique Gomez, 48, died from a spontaneous intracerebral haemorrhage during hospitalization for stroke rehabilitation and treatment of schizoaffective disorder. An initial ischaemic stroke resulted from non-co…

general medicineneurologywarfarin
VIChospital2025-04-30

Finding into death of Margaret Ann Day

66y · Female·Ischaemic brainstem stroke

…farcts with basilar artery occlusion, placing her outside the thrombolysis window. She was admitted to the Stroke Unit, commenced on anticoagulation and supportive care including nasogastric feeding. Despite antiepilepti…

neurologyemergency medicinelevetiracetam
VIC2025-05-29

Finding into death of Gary Mayrhofer

54y · Male·Complications following an old prior cerebrovascular accident - aspiration pneum…

…palsy, intellectual disability, epilepsy and visual impairment, died from aspiration pneumonia following a stroke in September 2023 that caused right-sided paralysis and swallowing difficulties. He spent eight weeks in h…

neurologydisability medicine
SAhospital2022-07-13

Coroner's Finding: Wotton, Jeremy Dane

57y · Male·brainstem and cerebellar infarction due to vertebrobasilar artery thrombosis

…to an ED with vertigo, blurred vision, and 'not feeling right' caused by an evolving posterior circulation stroke. A junior doctor discharged him after 3 hours, considering the vertigo peripheral rather than central. The…

emergency medicineneurologydiagnosticcommunicationprochlorperazine
VIChospital2017-07-13

Finding into death of Michelle Louise Rosevear

41y · Female·Left middle cerebral artery territory ischaemic stroke

…ness on 28 May 2015. She was initially assessed as having a possible medication overdose rather than acute stroke, despite later learning she had reported weakness on her right side and suspected stroke that morning. A C…

emergency medicineneurologydiagnosticdelayquetiapine
WAcommunity2019-02-06

Inquest into the Death of Torran Jake THOMAS

15y · Male·Multiple organ failure associated with hyperthermia (heat stroke)

A 15-year-old rugby league player died from heat stroke during training on an extremely hot Perth summer evening (44.4°C). The coaching staff appropriately applie…

emergency medicineintensive carediagnosticdelay
VIChospital2011-04-06

Finding into death of Keith Harrington Smith

81y · Male·pneumonia

Keith Harrington Smith, an 81-year-old man with significant medical comorbidities including previous stroke with dysphagia, heart disease, and chronic lung disease (bronchiectasis), died from pneumonia. He was admi…

general medicinerespiratory medicinemorphine
TAShospital2018-01-23

Coroner's Finding: Mr M

41y · Male·large volume thrombotic stroke within the distribution of the right posterior ce…

A 41-year-old man with acute posterior circulation stroke was misdiagnosed as encephalitis despite normal lumbar puncture findings. The critical failure was Dr R.'s…

emergency medicineneurologydiagnosticcommunication
VIChospital2023-05-24

Finding into death of Mr V

73y · Male·Combined effects of cerebrovascular accident and subsequent iatrogenic related i…

…ficulty on 5 September 2020. He was misdiagnosed with Bell's palsy despite clinical features suggestive of stroke. A non-contrast CT brain (inadequate for stroke evaluation) was performed instead of CT perfusion. He was …

emergency medicineneurologydiagnosticcommunicationprednisolone
VIChospital2010-05-20

Finding into death of Eileen May Howell

68y · Female·intracerebral haemorrhage

…rebral haemorrhage on 25 December 2008 while at her brother's home. She had been predicted to have another stroke within five years of her first event. No warning signs were noted by carers or family in the preceding wee…

neurosurgeryintensive care
VIChospital2025-10-10

Finding into death of Jeffrey George Nirens

70y · Male·intracranial haemorrhage secondary to haemorrhagic transformation of ischaemic s…

…erebral ischaemia died from intracranial haemorrhage following haemorrhagic transformation of an ischaemic stroke while in prison custody. He presented with acute stroke symptoms and was appropriately treated with dual a…

neurologyemergency medicinemedicationsystemenoxaparin
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