63 results for “missed approach”
Male·Multiple injuries due to or as a consequence of an aircraft accident (controlled…
…shed near Lockhart River, Queensland, killing all occupants. The pilot attempted two RNAV GNSS instrument approaches in poor weather with heavy rain and low visibility. During the second approach, the pilot was flying ap…
59y · Male·Pulmonary embolus
…stratification tools (Wells score/PERC rule) or seek senior consultation. The coroner identified this as a missed diagnostic opportunity and emphasised the importance of maintaining broad differential diagnosis in acute …
63y · Female·Combined features of bronchopneumonia, emphysema and ischaemic heart disease on …
…onia, emphysema, and ischaemic heart disease following a prolonged lie on the ground with hypothermia. She missed a routine appointment on 16 May 2023 at her community health clinic. Her daughter expected to be contacted…
60y · Female·Respiratory arrest in the setting of aspiration pneumonia; seizures associated w…
… suspension form. The facility failed to convey urgency to the GP, did not communicate that doses had been missed, and the GP did not review the medication administration record during her visit. Abrupt cessation of phen…
79y · Female·Dilated cardiomyopathy with decompensated heart failure not appropriately treate…
… have enabled her to survive the hospitalisation, though pneumonia developed later. The coroner identified missed opportunities in communication between specialists and failure to objectively measure fluid status.
35y · Male·Neck compression due to hanging
…ely would have discharged him anyway due to apparent improvement, each communication failure represented a missed opportunity to better inform assessment and tailor follow-up. The coroner recommended developing structure…
46y · Male·Haemopericardium complicating aortic dissection
…opericardium due to aortic dissection. The coroner found the death was preventable with proper diagnostic approach. Key lessons: aortic dissection must remain in differential for acute chest pain; avoid diagnostic anchor…
19y · Male·chest injuries caused by blunt force trauma suffered in a high speed motorcycle …
…peed monitoring protocols when the radar operator attempted to abort the jump attempt but the rider either missed or ignored the signal; lack of documented engineering calculations for the complex physics involved; and a…
15y · Female·neck compression due to hanging
…linary team. When Michaela disengaged in November 2011, CAMHS closed her file. Critical opportunities were missed: Seymour College and later Dr L. urged psychiatric involvement, but communication failures meant Michaela …
61y · Male·Coronary atherosclerosis
…'age-advanced atherosclerosis' on lumbar spine X-ray in 2016. Clinical Forensic Medicine review identified missed opportunities: baseline cardiovascular risk assessment was not performed despite diabetes diagnosis dating…
46y · Male·Cold environmental exposure in a man with cardiomegaly
… risk. The coroner found the death preventable due to failure to review overall risk prior to transition—a missed opportunity for safety planning.
13y · Male·borderline myocarditis, most likely due to influenza A virus infection
A 13-year-old previously healthy boy with borderline myocarditis presented to an adult ED with flu-like symptoms, lethargy, dizziness, syncope and inability to walk unaided. Despite these concerning features, he was disc…
20y · Male·pulmonary oedema due to acute on chronic heart failure resulting from dothiepin …
…ued for five months after becoming ineffective. Key clinical failures included: absence of dual diagnosis approach to comorbid mental illness and substance abuse; inadequate psychiatric follow-up after the therapeutic re…
18y · Male·gunshot wound to the head
…ernet searches for weapons, and expressed intent to harm law enforcement. While the coroner criticised the missed capture of Numan's comment 'if I had a knife I would've stabbed them', which might have altered police pla…
49y · Male·haemopericardium secondary to ruptured aortic dissection
…physician staffing (only one ED physician available). The coroner found the death preventable, identifying missed diagnostic opportunities. Key failures included: diagnostic bias towards coronary artery disease with fail…
7y · Female·Multiple abdominal injuries including traumatic rupture of the liver and stomach…
… a severe hypoglycaemic episode and seizure, and certified him fit to drive without proper assessment; (5) missed medical appointments following a serious hypoglycaemic episode requiring hospitalization should trigger ma…
32y · Female·Stab wound to the back extending into the posterior neck, causing subtotal trans…
Michelle Darragh, a 32-year-old social worker, was fatally stabbed by her former partner Benjamin Coman on 9 October 2021. She was pregnant with their third child. The relationship involved progressive coercive control, …
18y · Male·neck compression due to hanging
…sufficient recognition of chronic suicide risk, poor medication compliance without enforcement mechanisms, missed opportunities for crisis intervention in final weeks, and pressure to discharge from inpatient units witho…
39y · Male·ligature compression of the neck (hanging)
A 39-year-old man with schizoaffective disorder and substance abuse died by suicide following arrest for criminal damage. While treated under a Community Treatment Order, he had poor medication compliance and ongoing dru…
34y · Male·drowning
…linicians without shared care plan), excessive case manager caseload (32 consumers vs. recommended 15-20), missed clinical escalation opportunities despite multiple warning signs (McDonald's incident, medication non-comp…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.