Coronial

206 results for congestive cardiac failure

NSWaged care2025-01-24

Inquest into the deaths at Newmarch House

Unknown·COVID-19 infection with various comorbidities as contributing factors

…ol, severe staffing shortages, and suboptimal clinical management under a Hospital-in-the-Home model. Key failures included: delayed PCR testing allowing spread, incomplete Advance Care Plan discussions, inadequate pain…

geriatric medicineinfectious diseasessystemdiagnosticmorphine
QLDhospital2016-02-29

Mr B - Non-inquest findings

84y · Male·Acute myocardial infarction precipitated by upper gastrointestinal haemorrhage f…

An 84-year-old man with multiple comorbidities was prescribed rivaroxaban for deep vein thrombosis despite being a practicing Jehovah's Witness who refused blood transfusions. Rivaroxaban cannot be monitored or reversed,…

cardiologyhaematologymedicationcommunicationrivaroxaban
SAhospital2005-06-02

Coroner's Finding: GREEN Marie

64y · Female·Respiratory arrest secondary to morphine overdosage on a background of mild to m…

A 64-year-old woman died from respiratory arrest secondary to morphine overdose after ingesting 17 tablets of slow-release morphine (Kapanol) and diazepam. Initial emergency assessment by an intern was appropriate, but c…

emergency medicinegeneral medicinecommunicationdiagnosticmorphine
VICaged care2023-03-22

Finding into death of S M

91y · Male·Complications of cerebrovascular and ischaemic heart disease in a man post anaph…

…elevated inflammatory markers. He subsequently suffered a cerebrovascular event and died. Multiple system failures occurred across prescribing, dispensing, pharmacy software alerts, and nursing administration. Key learn…

geriatric medicinegeneral practicediagnosticmedicationdiltiazem
SAhospital2017-04-07

Coroner's Finding: MAYELL Edward John

83y · Male·pneumonia and severe acute respiratory distress syndrome caused by Legionella ba…

… initially misdiagnosed as having aspiration pneumonia rather than community-acquired pneumonia. Critical failures included: (1) radiology report showing pneumonia not communicated urgently by telephone to treating doct…

emergency medicinegeneral practicediagnosticmedicationceftriaxone
NTaged care2020-12-18

Inquest into the death of Barbara Francis

78y · Female·cardiorespiratory failure, ischaemic and hypertensive heart disease together wit…

… physiotherapy recommendations that she wear hip protectors 24/7, she was not wearing them due to laundry failures. The fall triggered rapid deterioration; she underwent hemiarthroplasty but died 14 days later from card…

geriatric medicineorthopaedic surgerysystemcommunication

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