34 results for “ultrasound (not performed)”
43y · Female·pulmonary embolism
… menstrual bleeding. Following the procedure, she developed left leg swelling on day 3. A Venous Doppler Ultrasound was performed but did not extend above the inguinal ligament. She was reassured after negative imaging a…
60y · Male·haemopericardium due to rupture of right ventricle complicating removal of cardi…
…y while an unproductive pulmonary angiogram was performed instead. The coroner found that had diagnostic ultrasound been immediately available, the haemopericardium diagnosis would have been made promptly, allowing earli…
33y · Male·Haemoperitoneum secondary to lacerated spleen as a result of peritoneal ascitic …
…. Two junior doctors (HMOs/Basic Physician Trainees) performed the procedure unsupervised without formal ultrasound training, mistaking the spleen for ascitic fluid. Critical failures included: absence of senior supervis…
Female·Combination of liver failure, blood loss and shock following needle biopsy
…atients, reassured nursing staff despite their concerns. A cardiac arrest occurred at 2:35 PM. Emergency ultrasound showed active portal vein bleeding and massive intra-capsular hemorrhage. Emergency surgery 4 hours late…
0y · Male·acute hypoxic damage caused by shoulder dystocia during delivery
…o caesarean section if needed. Antenatal recognition of the baby's large size (estimated 4.5 kg) through ultrasound could have influenced labour management decisions. The consultant obstetrician was not involved in the d…
31y · Male·Pulmonary thromboembolism arising from deep vein thrombosis
…/calf pain after flying. Despite risk factors (obesity, long-haul travel), DVT was not investigated with ultrasound. When he presented five days later with resolved leg pain, ultrasound was not pursued despite discussion…
43y · Male·Hypoxic brain injury secondary to haemopericardium and tamponade complicating ru…
…ration of the right ventricular outflow tract (RVOT), possibly from the drainage needle inserted without ultrasound guidance. Despite resuscitation and emergency transfer to a tertiary cardiac centre, he suffered irrever…
94y · Female·Complications of metastatic lobular carcinoma of the breast in a woman with deme…
A 94-year-old woman with advanced dementia and metastatic breast cancer died from complications of her malignancy. She presented repeatedly with vomiting due to duodenal obstruction from metastatic tumour, but this was n…
71y · Female·multiple pulmonary thromboemboli and deep vein thrombosis
…e leg pain/swelling over one week. ECG showed S1Q3T3 pattern consistent with pulmonary embolism; bedside ultrasound showed right ventricular strain. Despite presumptive diagnosis of PE being made, no anticoagulation or t…
42y · Male·disseminated metastatic renal cell carcinoma
…year-old prisoner died from disseminated metastatic renal cell carcinoma. Renal cancer was identified by ultrasound in September 2006 and confirmed by CT scan. Surgery was performed with curative intent in December 2006,…
71y · Female·Ruptured abdominal aortic aneurysm, with coronary artery atherosclerosis contrib…
… becoming dismissive of the local doctor; (3) the retrieving doctor (Dr J.) performed an inadequate FAST ultrasound, over-relied on a negative result, and incorrectly prioritized sepsis as the working diagnosis; (4) crit…
0y · Male·Intrapartum hypoxia due to true knot in umbilical cord with cord wrapped three t…
… made recommendations for improved data collection on umbilical cord abnormalities and future antepartum ultrasound screening capabilities.
83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)
…idental finding of an 8.7 cm AAA was identified on a lumbar spine X-ray in August 2021, but confirmatory ultrasound and CT imaging were not performed until February 2022. Critical failures included: the PMO's failure to …
25y · Female·ruptured splenic artery aneurysm with haemorrhage and internal blood loss
…gardless of initial stability; (2) consultant involvement was absent until final collapse; (3) a planned ultrasound examination was not carried out despite clinical deterioration; (4) the 'double rupture phenomenon' with…
0y · Male·subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour
…al position must be definitively established before instrumental delivery using clinical examination and ultrasound if uncertain; unaccredited registrars require direct supervisor presence; slow labour progression should…
81y · Male·valvular heart disease with cardiac amyloidosis
Murray Eric Clark, 81-year-old prisoner with extensive cardiac history including aortic stenosis, sick sinus syndrome with pacemaker, and recent TAVI procedure, collapsed and died in prison infirmary on 20 September 2019…
72y · Female·haemorrhage from penetrating duodenal ulcer
A 72-year-old woman collapsed at home and was admitted with black bowel motions (melaena) suggestive of gastrointestinal bleeding. This crucial history was documented by the ED doctor but not properly acted upon by the a…
0y · Female·Hypoxia resulting from primary idiopathic pulmonary hypertension of the newborn …
Jasmine Chiang died at 7 hours of age from primary idiopathic pulmonary hypertension of the newborn (PPHN), probably complicated by pulmonary haemorrhage. She presented with classic PPHN signs (harlequin appearance, diff…
68y · Female·Multi-organ failure associated with septic shock following duodenal perforation …
Athenia Hana Walden, 68, died from multi-organ failure and septic shock following duodenal perforation during laparoscopic surgery at Swan District Hospital on 8 May 2008. Surgery was performed to remove her gallbladder,…
1y · Female·cystic encephalomalacia
Lilly Ella Daw, born at 27 weeks gestation as a monochorionic diamniotic twin following intrauterine death of her co-twin, died at one month of age from cystic encephalomalacia. The surviving twin had a documented 20% ri…
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