| 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.” |
|
| 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.” |
|
| 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.” |
|
| 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
|
