332 results for “emergency patient transfer”
24y · Male·Massive blood loss caused by incised wounds of left upper extremity
A 24-year-old man with schizophrenia and psychotic symptoms died from massive blood loss after self-inflicted wrist lacerations in prison custody. He called for help twice via the cell alarm system at 9:17pm and 9:23pm, …
66y · Male·Complications of metastatic lung adenocarcinoma, with terminal palliative care, …
…ed decision to refuse potentially curative treatment. Holmes rapidly deteriorated in January 2023 and was transferred to Fiona Stanley Hospital where he died. The coroner commended the medical care but identified issues:…
64y · Male·Complications of Creutzfeldt-Jakob Disease following a fall
…n (rivaroxaban). Over subsequent days he deteriorated with stiffness, fever, and decreased consciousness. Transfer to ICU revealed bilateral occipital haemorrhage on CT, status epilepticus on EEG, and ultimately sporadic…
36y · Male·Multi-organ failure due to consequences of multiple injuries sustained following…
… psychiatric ward after a failed community trial. Despite being a documented high absconding risk, he was transferred from the secure closed ward to an open ward to accommodate more acute patients. Within hours, after re…
67y · Male·Complications of pressure ulcers in the setting of a thoracic vertebral fracture…
Michael Young, 67, died from pressure ulcer complications following a spinal injury sustained during a CT scan on 3 January 2023. He had fallen from his wheelchair at home and presented to ED with hypotension and back pa…
68y · Male·compression of the neck with contributing acute myocardial infarction due to cor…
… his cell at Yatala Labour Prison on 16 April 2015 while experiencing acute myocardial infarction. He was transferred to Yatala for urgent psychiatric assessment following two self-harm attempts at Port Augusta Prison in…
37y · Male·Posterior myocardial infarction consequent upon right coronary artery thrombosis…
… healthcare equivalent to the general public and that correct diagnosis would likely have led to hospital transfer and survival. Queensland Health subsequently implemented reforms including improved screening protocols, …
16y · Female·intra-abdominal haemorrhage due to ruptured spleen
…ipped Berri Hospital, following standard rural ambulance protocol. At Renmark, she received high-quality emergency care but lacked adequate blood supplies (only one unit of O-negative available) and surgical facilities.…
31y · Male·ligature compression of the neck (hanging)
A 31-year-old man with depression, suicidal ideation, and recent HIV diagnosis presented to emergency department after suicide attempt (carbon monoxide inhalation and diazepam overdose). Despite psychiatris…
85y · Female·Staphylococcus bacteremia complicating multiple injuries sustained in a motor ve…
An 85-year-old woman sustained multiple serious injuries (bilateral rib and pelvic fractures, thoracic spine fractures) in a motor vehicle collision on 20 June 2018. She was treated with ICU admission, induced coma, and …
65y · Female·Early bronchopneumonia and hypoxic brain injury following aspiration of food (ch…
…ant schizophrenia, died from aspiration choking while eating on a psychiatric ward. She had been recently transferred to a rehabilitation unit for reassessment of her complex medication regimen. While eating a sandwich, …
52y · Male·ischaemic heart disease
Hassan Bechara, a 52-year-old prisoner, died from ischaemic heart disease in July 2017. He had complex cardiac history including dilated cardiomyopathy, triple-vessel coronary disease, and previous cardiac procedures. Cl…
22y · Unknown·sudden death associated with volatile substance inhalation (butane and propane)
…ledged this death was preventable and attributed it to absent clear procedures for managing mental health patients in general wards.
63y · Male·Right cerebral infarction caused by infusion of medication via central venous li…
A 63-year-old man with COPD, liver cirrhosis and alcohol dependence underwent emergency hemicolectomy for caecal volvulus. Post-operatively he developed respiratory depression, hypernatremia a…
66y · Male·Cardiac arrhythmia in a man with arteriosclerotic cardiovascular disease, pulmon…
…bility issues and no escape risk, Stinson was restrained with leg chains and mechanical restraints during transfer to hospital and remained restrained until 28 January 2022 when doctors intervened. The coroner found this…
44y · Male·Cardiomegaly
…ardiomegaly (enlarged heart due to concentric ventricular hypertrophy) while an involuntary psychiatric inpatient. He presented with hypertension and withdrawal symptoms on admission; initial management including transf…
89y · Male·combination of biochemical consequences of colonic pseudo-obstruction and faecal…
An 89-year-old man with multiple comorbidities including previous colon cancer died from faecal impaction and stercoral colitis. He resided in a residential aged care facility (RACF) where staff failed to recognize that …
37y · Male·Coronary artery thrombosis resulting from coronary atherosclerosis with contribu…
…nd unexplained pain, the ambulance officers decided not to transport him to hospital, claiming he refused transfer. The deceased died approximately 3 hours later from coronary artery thrombosis with contributing valve di…
49y · Male·Acute myocardial infarction complicating prosthetic valve thrombosis in a man wi…
…s, poor handover between Monash Health and Dorevitch Pathology regarding warfarin management, and delayed patient registration with missing clinical information. The coroner found no single shortcoming would have preven…
78y · Female·Blunt force trauma to the head caused by a compressor from a refrigeration unit …
…sed on human factors, lack of standardised human factors data collection, and communications gaps in the emergency response (failure to include ambulance and rail representatives in the incident management committee). T…
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