123 results for “x-ray imaging”
57y · Female·Haemothorax following acute thoracic aortic dissection in a woman with congenita…
…uspid aortic valve, presented to ED on 23 March 2012 with severe acute back and chest pain (8/10). A chest X-ray revealed widened mediastinum. She was admitted to CCU under cardiologist Dr G.. Over 8 days, her presentat…
34y · Male·multi-organ failure with right-sided tension pneumothorax
…despite clear indicators of serious pathology: severe pain (15/10), tachycardia (138-121 bpm), and a chest x-ray showing left base consolidation and pleural effusion concerning for pneumonia. The x-ray report was unavai…
91y · Female·Complications of pelvic fractures sustained in a fall
…idities sustained pelvic fractures in a mechanical fall at home. She presented to the ED where initial hip x-ray showed no fracture. She deteriorated with hypotension and was treated with antibiotics for presumed pneumo…
83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)
…nostic confirmation and treatment. An incidental 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. Critica…
78y · Female·sepsis and aspiration with metabolic dysfunction as a result of mechanical small…
…spital emergency department on 16 November 2007 with a misdiagnosis of constipation, despite clinical and imaging features diagnostic of small bowel obstruction caused by abdominal adhesions from previous surgery. She h…
62y · Female·gastric necrosis and perforation due to strangulated diaphragmatic hernia
…h Act at Queen Elizabeth Hospital. She presented with vomiting and abdominal pain from 5-8 February 2007. Imaging on 6 February revealed the hernia with recommendation for clinical correlation, but no gastroenterologica…
40y · Male·haemopericardium complicating ascending thoracic aortic dissection
…two days later from rupture of an ascending thoracic aortic dissection with haemopericardium. Post-mortem imaging revealed widened mediastinum on the initial chest x-ray. The coroner found preventable failures: the x-ra…
66y · Male·carcinomatosis complicated by recurrent sepsis and multisystem failure in a man …
…nd multisystem failure. Critical clinical lesson: haematuria in 2005 was not adequately investigated with imaging despite recurrence and negative infection workup. A prison doctor (Dr H.) initially recognised the need f…
71y · Female·pneumonia following cervical spine fracture sustained in motor vehicle collision
…elow acceptable standard. Prevention required adherence to existing cervical spine protocols, appropriate imaging in elderly trauma patients, and proper clinical correlation with imaging findings.
89y · Female·Pulmonary embolism due to deep venous thrombosis
…ay delay. The coroner found Dr D.-Mustapha's initial ED assessment was inadequate; she failed to order hip X-rays despite a clear history of fall with hip pain, mobility loss, and inability to weight bear. The coroner w…
38y · Male·metastatic lung carcinoma
…ht loss, poor appetite, and a persistent cough. Despite multiple medical consultations and investigations (X-rays, CT scans), imaging focused on musculoskeletal pathology and missed the underlying malignancy. When sent …
31y · Female·raised intracranial pressure due to ventriculoperitoneal shunt dysfunction (disc…
…h 2010 with progressive headaches, cognitive changes and behaviour deterioration. Investigations including x-rays clearly showed the peritoneal catheter disconnected at C4-C5 level, but the neurology team misinterpreted…
63y · Male·Metastatic carcinoma of the lung
…March 2008 was addressed only by telephone consultation rather than face-to-face examination, and no chest X-ray was ordered despite persistent respiratory symptoms and antibiotic relapse. While earlier diagnosis would …
44y · Male·Metastatic small cell neuroendocrine carcinoma of lung
…role. He had presented to PAH emergency department on 28 September 2010 with respiratory symptoms. A chest x-ray that day revealed a mediastinal density reported by radiology as possibly requiring CT investigation, but …
69y · Male·Perforated bowel/septicaemia as a result of diverticulitis
…litis. Critical failures included: missing early signs of serious intra-abdominal pathology (elevated WCC, x-ray findings suggestive of small bowel obstruction, low albumin, tachypnoea, low oxygen saturations); inapprop…
34y · Male·Haemopericardium due to dissecting thoracic aortic aneurysm
…sions, the ED was at full capacity ('Access Block'). He left without being seen both times, before a chest X-ray could be performed. He died the next morning from dissecting thoracic aortic aneurysm causing haemopericar…
26y · Female·cardiorespiratory arrest due to massive gastric dilatation with gastric rupture
…nd was available on the hospital computer system he was unaware of. Had this report been read and further imaging pursued, the diagnosis might have been made. The case demonstrates failures in: familiarisation with diag…
1y · Female·Dilated cardiomyopathy
…gnosis not reconsidered despite lethargy unusual for croup and lack of typical diurnal variation; no chest X-ray obtained when persistent tachypnoea should have prompted imaging. Earlier diagnosis with chest X-ray would…
18y · Female·Severe cardiogenic shock caused by myocarditis as a consequence of an unknown vi…
…is on 31 May but did not recognise the underlying cardiac deterioration. Cardiologists agreed that a chest X-ray, ECG and echocardiogram ordered by 28 May when coarse lung crepitations were noted would have revealed the…
55y · Male·ruptured dissection of the thoracic aorta
…ber 2010 and was transferred to Swan Districts Hospital where initial investigations (ECG, troponin, chest X-ray) were non-diagnostic. A widened mediastinum on repeat chest X-ray prompted urgent transfer to RPH where CT…
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