267 results for “severe heart failure”
35y · Male·Cardiac arrest due to incessant ventricular fibrillation/ventricular tachycardia…
…on (likely caused by trauma-induced coronary artery injury or stress-related plaque rupture), resulting in severe heart damage. He died 8 months later from cardiac failure. Key clinical failures: ECG results were not sho…
87y · Female·combined effects of ischaemic heart disease and chronic obstructive pulmonary di…
Epenesa Pahiva, 87-year-old resident with dementia at an aged care facility, suffered severe chemical burns from inappropriate bleach treatment prescribed by dermatologist Dr B.. The coroner found th…
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…
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…
86y · Female·subdural haemorrhage due to or as a consequence of a fall
Ms SME, an 86-year-old resident at a Blue Care nursing home, suffered a fatal subdural haemorrhage following a fall from bed during a sponge bath on 18 January 2016. She died on 21 January 2016. Clinical lessons include:…
61y · Male·cardiac tamponade caused by aortic dissection due to hypertension
Harry Coxell, a 61-year-old man with hypertension, presented to Blacktown Hospital with severe sudden-onset chest pain on 31 October 2006. The Emergency Department doctor, Dr H., assessed him as interm…
62y · Male·Global cerebral ischaemia secondary to intra-operative hypotension following the…
…perative hypotension after protamine administration during a cardiac ablation procedure. He had suffered a severe hypotensive reaction to protamine 8 days earlier during coronary artery bypass surgery, which was inadequa…
41y · Male·Cerebral hypoxia and bronchopneumonia; contributing factors: toxic megacolon, ce…
David Orton, a 41-year-old man with cerebral palsy, intellectual disability, and severe kyphoscoliosis, died from cerebral hypoxia and bronchopneumonia complicated by toxic megacolon and Salmone…
50y · Female·septicaemia
…esuscitation but she was declared dead on arrival. Autopsy revealed septicaemia with widespread infection (heart, lungs, kidneys, abscess formation), likely precipitated by intravenous drug use, poor dentition, or possi…
57y · Male·Severe coronary artery disease. It is likely that Kevin's use of inhalants in cu…
Kevin Bugmy, a 57-year-old Aboriginal man, died of severe coronary artery disease while in custody at Cessnock Correctional Centre. The coroner found the care recei…
0y · Female·Hypoxic-ischaemic encephalopathy in the setting of chronic placental insufficien…
Emma, born 26 July 2011, developed severe hypoxic-ischaemic encephalopathy associated with chronic placental insufficiency and died at 4 days old. H…
48y · Male·Coronary artery disease precipitating acute myocardial infarction resulting in c…
…0 August 2016 with chest pain and rib injury from an intoxicated fall. Critical clinical lessons include: failure to perform ECG despite persistent tachycardia (HR 152); misattribution of vital sign abnormalities to alc…
32y · Male·Asphyxia in a man with Friedreich's Ataxia due to positional asphyxia; unable to…
…is wheelchair. He had deteriorated significantly after hospitalisation in June 2013 and was weakened, with severe coughing fits. On 24 July 2013, no evening carer was rostered to assist him to bed due to communication fa…
44y · Female·Cardiac arrest in the context of several contributory factors (physical exertion…
…ty hood. She suffered cardiac arrest attributed to multiple contributory factors: significant pre-existing heart disease (cardiomyopathy, coronary atherosclerosis, obesity), physical exertion during restraint, psycholog…
47y · Male·Sudden cardiac death in association with COVID-19 infection
…e-wide outbreak. Despite obesity and schizophrenia as risk factors, no clinical observations (temperature, heart rate, respiratory rate, oxygen saturation) were performed after his positive test, contrary to Justice Hea…
Unknown·Multiple: Olanzapine toxicity, pulmonary thromboembolism, asphyxiation on food, …
…tween June 2009 and August 2010. All residents had schizophrenia on multiple antipsychotic medications and severe, untreated physical comorbidities (cardiac disease, COPD, obesity). The coroner found preventable clinical…
56y · Female·hypoxic ischaemic encephalopathy due to inadvertent oesophageal intubation and f…
…ncluded: difficult airway anatomy, chaotic MET environment, inadequate team leadership and communication, failure to promptly utilise capnography monitoring (gold standard), and false reassurance from tube fogging and b…
75y · Male·Acute cardiac failure due to mitral valve disease (surgically treated)
… based primarily on gastrointestinal bleeding symptoms, as TPCH lacked gastroenterology services. At RBWH, severe mitral valve regurgitation (4/4) was confirmed with progressive deterioration. After 12 hours, he was tran…
68y · Female·Anaphylaxis in a woman with atherosclerotic cardiovascular disease and emphysema
A 68-year-old woman with severe COPD and undiagnosed atherosclerotic heart disease underwent cataract surgery at Northam Hospital. Post-op…
Unknown·COVID-19 infection with various comorbidities as contributing factors
…use residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical management under a Hospital-in-the-Home model. Key failures in…
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