538 results for “observation”
61y · Male·exposure and dehydration, preceded by alcohol withdrawal and chronic alcoholism
…appropriate medication, but left hospital unobserved approximately 20 minutes after his last documented observation. He was last seen by a wardsman walking away from the hospital appearing competent. He wandered into bu…
30y · Male·hanging
Arthur Smith, a 30-year-old man remanded in custody, died by hanging in Yatala Labour Prison on 13 January 2005. He had a complex psychiatric history including borderline personality disorder, chronic depression, polysub…
25y · Male·acute heat stroke
Trooper Angus Lawrence, a 25-year-old soldier, died from acute heat stroke on 10 November 2004 during a military training exercise at Mount Bundey, NT. He collapsed during a patrol and despite rapid evacuation and intens…
44y · Male·Drowning
…clothing selection, equipment maintenance standards, weather-appropriate work practices, and continuous observation of dinghy operators.
61y · Male·Metastatic lung cancer (palliated)
…progressively unresponsive in his final week and was found deceased approximately 20 minutes after last observation. The death was expected in the context of terminal cancer and established palliative care pathway. No c…
29y · Female·asphyxiation due to ligature compression of the neck (hanging)
Wendy Anne Eadie, 29, died by suicide in Graylands Hospital's Frankland Centre on 1 November 1998 while detained following charges of unlawful wounding against her parents. She had a longstanding history of depression, c…
24y · Male·Complications of Brown Snake Bite
…ng the snake from his dog and was transported to Tamworth Base Hospital. Despite appropriate triage and observation, he developed sudden collapse and cardiac arrest approximately 25 minutes after arrival, with no prior …
52y · Female·intracerebral haemorrhage in a lady with underlying cerebrovascular disease and …
…, and abnormal behaviour over 6–7 April. Despite a critical BP spike of 220/110 and multiple concerning observations documented by nursing staff, the findings of nursing staff regarding blood pressure parameters and the…
45y · Male·Hypoxic-ischaemic encephalopathy due to prolonged hypoxia
…sues included failure to perform adequate pre-anaesthetic risk assessment, inadequate documentation and observation of sedation levels despite published PCA guidelines, non-contact with the Acute Pain Management Service…
23y · Male·combined drug toxicity (methadone, clozapine, quetiapine, diazepam, chlorpromazi…
…ion. Critical gaps emerged: the Next Step prescriber (Dr C.) did not communicate the specific risks and observation requirements to hospital doctors; Alma Street ward staff received no specific instructions about methad…
33y · Male·Neck compression (hanging)
…t, and presented with anxiety and withdrawal symptoms. Initially assessed as medium risk with 60-minute observations, his risk was downgraded to low with 120-minute observations after two days based on self-reported imp…
73y · Female·neck compression by ligature
…mental health history. Had the family's concerns been properly escalated to the psychiatrist, intensive observation and high-risk management strategies would likely have prevented her death.
37y · Male·blunt force injuries to the head and chest from jumping off an 8.65 metre roof
…rd, following assessment in the ED. He was assessed as highest risk for suicide but placed on 15-minute observations rather than one-to-one nursing care. Despite staff awareness that patients could abscond over the cour…
60y · Male·Global cerebral ischaemia post cardiac arrest in the setting of neck compression
…ed on and apply institutional risk assessment policies; and escalation to High Dependency Unit with 1:1 observations was warranted given his history. The coroner found reasonable clinical judgment in placement and commu…
17y · Female·multiple internal injuries sustained in motor vehicle collision
…e hospital treatment, she died from her injuries. This case illustrates the importance of comprehensive observation at intersections, particularly when turning across pedestrian paths, and the risks of distraction while…
64y · Male·Foreign body associated small bowel obstruction
…Griffin remained asymptomatic until his death. The coroner found that Dr P.'s clinical management using observation and serial x-rays was appropriate, and that Churchill staff provided appropriate supervision and precau…
24y · Male·unascertained
Louis Gerard Le Boeuf, aged 24, disappeared from the Sunbury Training Centre on 23 November 1977. He had severe epilepsy, intellectual disability, and required full support for daily living including assistance with walk…
72y · Female·Pneumonia following cervical spine injuries sustained in an unwitnessed mechanic…
…pinal injury (approximately two weeks), caused by deviations from protocols and incomplete neurological observations. The Root Cause Analysis identified multiple systems failures including inadequate neurological assess…
34y · Female·Multiple injuries sustained in a motor vehicle incident (pedestrian), in circums…
Melissa Gaultier, 34 years old, was discharged from Latrobe Regional Hospital's psychiatric ward (Flynn Unit) less than 24 hours after admission on 13 April 2017, despite comprehensive warnings from Monash Health that sh…
65y · Male·hypoxic ischaemic encephalopathy complicating hanging
…f the underlying steroid-induced syndrome, failure to maintain the ITO, cessation of one-to-one nursing observation, non-implementation of recommended antipsychotic medication, and absence of proper psychiatric follow-u…
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