Brendan BURNS

Inquest into the death of Brendan BURNS Decision of Deputy State Coroner Dillon on 9 May 2014 CATCHWORDS CORONIAL LAW – Cause and manner of death – Hospital death – Misdiagnosis of seriously-ill patient in emergency department – Failure to identify patient as critically ill – Flaws in clinical decision-making — Systems shortcomings – Need for improved systems and training of regional surgeons

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