332 results for “emergency patient transfer”
59y · Female·sepsis due to faecal peritonitis due to perforation of sigmoid colon complicatin…
… benign ovarian cyst. The perforation was repaired during the initial surgery, but the repair failed. The patient deteriorated at home and was readmitted. The primary issue was delay in performing emergency re-operation…
37y · Male·Multiple injuries (motor vehicle impact – pedestrian)
Justin Connell, a 37-year-old man with schizophrenia, died from multiple injuries sustained in a pedestrian–motor vehicle collision on 13 February 2013. He had been diagnosed with schizophrenia in October 2012 and prescr…
93y · Female·acute right lower limb ischaemia
…t worsened despite paracetamol treatment. The facility failed to obtain urgent medical review despite the patient's repeated requests for hospital transfer and family pleas for escalation. Key failures included: inadequ…
69y · Male·asphyxia by hanging
…ed: incoming nurse was not informed of his psychiatric history, suicidal ideation, or planned psychiatric transfer. Despite previous suicide attempt and increasing agitation, he absconded the next morning and died by sui…
30y · Male·Complications of methylamphetamine toxicity
…dia, chest pain) around 5:22pm and promptly contacted Custodial Health Advice Line and arranged ambulance transfer within 30 minutes. At Wimmera Base Hospital ED, there was a documented 90-minute delay in senior medical …
79y · Female·multiple injuries sustained in collision between semi-trailer and train
…oo late to stop. The collision exposed multiple systemic failures: inadequate training of train staff in emergency roles, absent or ineffective coordination between emergency agencies, delayed or inappropriate decisions…
64y · Male·plastic bag asphyxia
… ideation and attempting self-harm with a hacksaw. Despite family warnings about his suicide risk, he was transferred from intensive psychiatric care to an open ward on 15-minute observations. He created a dummy in his b…
78y · Male·Acute pancreatitis
…g with nausea and vomiting at Thomas Embling Hospital (a forensic mental health facility). He was rapidly transferred to Austin Hospital where CT imaging confirmed acute interstitial oedematous pancreatitis. Despite supp…
0y · Male·Complications of small bowel obstruction due to post operative adhesions
…nal and thoracic surgery in a vomiting infant, and provided only an equivocal recommendation for hospital transfer. The mother expected transport to the Royal Children's Hospital. The coroner found the history-taking uns…
58y · Female·lymphangitic carcinomatosis leading to hypoxaemic respiratory failure and cardia…
…ncies did not affect outcome; she died from natural disease progression. The coroner found early hospital transfer was not definitively required, though better monitoring and adherence to ALS protocols would represent op…
32y · Male·Head and neck trauma (train impact)
Travis Hartskeerl, a 32-year-old man with a complex history of schizophrenia, polysubstance abuse, and multiple serious suicide attempts, died by suicide on railway tracks on 16 December 2008. He had been discharged from…
42y · Male·Hypoxic encephalopathy in the setting of recent acute myocardial infarction with…
Ruben Chand, a 42-year-old male, suffered a fatal hypoxic brain injury during emergency re-intubation in ICU. After an initially reasonable extubation decision, he deteriorated and required ur…
66y · Female·Pulmonary thromboembolism due to renal vein thrombus secondary to renal cell car…
…d the treating surgeon was unaware of her presentation. The case highlights critical system deficiencies: patients waited up to 88 days from outpatient assessment to theatre despite Category 1 urgency; there were no est…
17y · Male·ligature compression of the neck (hanging)
Jesse Dellar, a 17-year-old with a history of ADHD, learning disability, depression, and childhood sexual abuse, was admitted to Albany Regional Hospital on 23 November 2010 after intentionally overdosing on his ADHD med…
23y · Male·hanging
A 23-year-old male with treatment-resistant schizophrenia died by hanging while an involuntary patient in the High Dependency Unit of Royal North Shore Hospital. He presented acutely on 4 February 2019 with s…
21y · Female·Multiple organ failure as a result of overwhelming Streptococcus pyogenes (Group…
Sara Hampel, 21 years old, died from sepsis caused by necrotising fasciitis (Group A Streptococcus) on 14 October 2011, presenting 8 days post-partum with severe leg pain and multiple signs of sepsis. Critical failures i…
20y · Male·ruptured heart and aorta due to fall from a height
…l security until approximately 3.5 hours after his disappearance was noted, and the procedure for missing patients lacked clear timelines. The coroner found that an alarm should have been raised to security within 30 mi…
74y · Female·Multiple injuries sustained when struck by train
…er, depression, anxiety and type 2 diabetes died by suicide after absconding from Fiona Stanley Hospital Emergency Department. She had been on extended psychiatric admission and transferred to transitional care, where s…
43y · Female·Hypoxic ischaemic brain injury resulting from alcohol and sodium valproate toxic…
43-year-old woman with epilepsy and depression died from hypoxic ischaemic brain injury after ingesting 15g sodium valproate and 750ml vodka. Critical failures occurred across multiple settings: VPIC provided incomplete …
70y · Male·Coronary atherosclerosis
…uld have been initiated at admission; (2) Antihypertensive medications were discontinued in 2011 when the patient refused them due to side effects and were not resumed for years, despite hypertension being a major modif…
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