List of Coronial Findings

Posted on
Coronial Inquest into the death of:

Date of Findings

Catchwords

Issues relevant to nursing and midwifery:
Mahmoud ALLAM

Link to Finding		 25 March 2020 “Death in custody, Parklea Correctional Centre, Methicillin-Resistant Staphylococcus Aureus, observations, antibiotic therapy, Therapeutic Guidelines: Antibiotic.”
  • Assessment
  • Observation
  • Documentation
Esteban FRANCO-GARCES

Link to Finding		 17 March 2020 “hospital death of a two month old boy –delayed recognition of sepsis – inadequacy of senior doctor overview – inadequate handover-prolonged attempts at intravenous access-delayed administration of antibiotic –inadequate co-ordination of care.”
  • Handover 
  • Communication
  • Coordination of care
  • Delay in escalation
  • Delay in administration of antibiotics
Paul MORTIMER

Link to Finding		 4 March 2020 “Death of patient following colorectal surgery – was discharge planning and post discharge care appropriate – did retained surgical sponge cause or contribute to death.”
  • Count in theatres
  • Communication
  • Documentation
Hazel BROCKETT

Link to Finding		 3 March 2020 “Manner of death – Residential Aged Care Facility – Resident to Resident Aggression in dementia unit – policies and procedures – identifying cause of behaviour and reporting incidents – actions taken to prevent escalation of behaviour – whether actions adequate”
  • Communication
  • Multi-Disciplinary/ Team approach to care
Harold EDWARDS

Link to Finding		 29 November 2019 “Cause and manner of death- involuntary patient-Mental Health- suicide-nurses’ failure to carry out observations-falsified Observation Charts sheets- missing documents-time of death- uncertain medical records.”
  • Communication
  • Documentation
  • Care level observations
Six patrons of NSW music festivals,
Hoang Nathan TRAN
Diana NGUYEN
Joseph PHAM
Callum BROSNAN
Joshua TAM
Alexandra ROSS-KING

Link to Finding		 8 November 2019 “Manner of death, death at music festival, MDMA toxicity, harm minimisation strategies, policing of music festivals, drug checking, drug monitoring schemes, drug education.”
George KIMPTON

Link to Finding		 8 October 2019 “death in hospital following colorectal surgery – cause and manner of death – was Mr Kimpton’s medical and nursing care adequate and appropriate?”
  • Administration of PCA Morphine
  • Escalation and request for medical review
  • Deteriorating patient
  • Frequency of vital sign observations
Jarod WRIGHT

Link to Finding		 18 Jan 2019
(Fresh Inquest)		 “Whether necessary or desirable for recommendation to be made regarding nursing/patient ratios.”
  • Ratios
  • Communication
Jarod WRIGHT

Link to Finding		 17 December 2018
(First Inquest)		 “Cause of death – cellulitis and hypoxaemia – was nursing/patient ratio in ICU appropriate – was hypoxaemia appropriately treated – are changes needed to hospital’s monitoring and alarm systems.”
  • Ratios
  • Communication
W

Link to Finding		 12 September 2018 “Drug withdrawal management centre – inpatient with multiple dependencies – was death caused by multidrug toxicity – were buprenorphine doses appropriate– recommendations.”
  • Observation
  • Documentation
  • Medication Administration
  • CPR
Phillip IBRAHIM

Link to Finding		 24 August 2018 “Manner of death and central venous Access Devices.”
  • CVAD and IV line
  • Clamping
  • Delay
Paul LAU

Link to Finding		 29 March 2018 “Cause and manner of death TrakCare, Electronic medical records Anaesthetics, Opioids, Fentanyl Handover practices.”
  • Medications
  • Handover
  • Communication
  • Observation
MA

Link to Finding		 2 February 2018 “Suicide risk assessments and risk levels Nursing engagement and observation levels in Mental Health Units”.
Aliha RAFTERY

Link to Finding		 12 September 2018 “self-inflicted death, adolescent mental health, psychiatric intensive care unit, Mater Mental Health Centre, transfer of care, patient observation levels, risk assessment, handover process, ISBAR, nurse-to-patient ratios, back- to-base pulse oximetry.”
  • Handover
  • Observation
  • Communication
  • Ratios
AR

Link to Finding		 6 April 2017 “Cause and manner of death; death in residential care facility; drug toxicity (Fluvoxamine); SUDEP; adequacy of care and treatment.”
  • Medications
  • Rounds
Shona HOOKEY

Link to Finding		 22 December 2016 “Cause and manner of death – Hospital death – Disabled patient unable to speak – Undiagnosed twisted bowel — Whether response at care facility was appropriate – Whether response at hospital was appropriate — Whether patient could have survived if response different – Improvements to systems.”
  • Escalation
  • CPR
  • Documentation 
Lynette Maree YOUNG

Link to Finding		 27 July 2015 “care and treatment, inadequate handover, failure to recognise deteriorating condition and failure to respond, recommendations.”
  • Escalation
  • CPR
  • Documentation 
Sybil ZIMMERMAN

Link to Finding		 14 March 2014 “Nursing home death, cause and manner of death, whether decease overdosed with medication, if so, whether overdose contributed to death, whether gross negligence or homicide by nursing staff – unfounded allegations – comment by coroner.”
  • Medication Administration

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