538 results for “observation”
75y · Male·Hanging
… Broadmeadows Aged Psychiatric Mental Health Service on 21 September 2013 and placed on 15-minute close observations due to high suicide risk. A blue plastic slip sheet, placed by staff as a temporary curtain to reduce …
21y · Female·Multiple organ failure due to undefined sepsis (toxic shock syndrome)
…0pm on 14 March when her blood pressure declined significantly. Dr M. was not notified of this critical observation. When contacted at 2:05am on 15 March about ongoing vomiting, he initially managed her as hypovolemic s…
27y · Female·hanging
…gular risk assessments and mental state examinations per unit policy; inadequate nursing engagement and observation, particularly on the day of death when mental state was deteriorating; and failure to recognise and esc…
29y · Male·Sudden Unexpected Death in Epilepsy (SUDEP)
Dean Broughton, a 29-year-old man with hyperekplexia and possible epilepsy living in an assisted living facility, was found deceased at home. Autopsy and review of medical records confirmed Sudden Unexpected Death in Epi…
62y · Female·Unascertained
Marilyn, a 62-year-old woman with schizophrenia and intellectual disability, died at Caulfield Hospital on 27 October 2019 with an unascertained cause. She was admitted via the ED under mental health legislation with det…
55y · Male·Hanging
…ation of risk assessment regarding personal items, nursing staff basing decisions to retain the belt on observation frequency (60-minute) rather than actual risk level, and lack of explicit psychiatric direction to remo…
40y · Female·hypoxic ischaemic encephalopathy due to ligature compression of the neck
… policy recommended. From 6:32pm onwards, she received no physical checks despite requiring 30-minutely observations under the approved DRA. By 7:13pm she had asphyxiated using the blanket. Resuscitation efforts continu…
76y · Male·Upper airway obstruction by food bolus in a man with ischaemic heart disease
…sphagia risk in elderly patients with acute psychiatric illness, and the importance of eating behaviour observation in vulnerable populations.
34y · Male·cardiomegaly with contributing aspiration
A 34-year-old man with paranoid schizophrenia, morbid obesity, type 1 diabetes, and undiagnosed sleep apnoea died from cardiomegaly with contributing aspiration while detained under the Mental Health Act. On 6 March, he …
53y · Female·Ligature strangulation
…erious self-harm. On 25 January 2017, Registered Nurse Pare conducted an 'at risk' assessment following observation of bruising around her neck. The assessment was conducted through a cell door window, with limited dire…
69y · Female·faecal peritonitis due to small bowel obstruction and perforation due to periton…
A 69-year-old woman presented to the Emergency Department with abdominal pain and vomiting. The doctor did not take adequate history, perform thorough physical examination, or order basic investigations including blood t…
74y · Male·Incised wounds to limbs; other significant conditions being ischaemic heart dise…
Garry Reginald Dubois, a 74-year-old serving a life sentence for serious offences, died in custody from self-inflicted incised wounds to his limbs. He was on dual antiplatelet therapy for ischaemic heart disease, which c…
35y · Male·multiple injuries received when he fell from a 13th floor balcony
…rrest and attempting to climb balconies. Police arranged appropriate containment including ground-level observation of the balcony. The coroner was not persuaded that placing police on the lower balcony would have been …
13y · Female·cerebral oedema and infarction secondary to extensive subdural empyema
Elly McCarthy, a 13-year-old girl, died from cerebral oedema and infarction secondary to subdural empyema. She developed fever, headache and neurological symptoms on 24 January 2004 and was initially seen at a GP and Noa…
24y · Male·plastic bag asphyxiation
Sean Kevin Hayes, a 24-year-old male remand prisoner, died from plastic bag asphyxiation in his cell at Canning Vale Remand Centre in Western Australia on 20-21 August 1997. He had a history of psychiatric illness, previ…
69y · Male·complications post trauma related acquired brain injury
…jury and how pre-existing neurological damage increases vulnerability to acute infections. The family's observation that the assault shortened his life was supported by medical evidence.
0y · Female·Group B Streptococcus meningitis and sepsis
An 18-day-old baby died from late-onset Group B Streptococcus (GBS) meningitis and sepsis. She was born at a regional private hospital after labour complicated by maternal fever (37.6°C), foetal tachycardia (160-170 bpm)…
38y · Male·cardiac arrest precipitated by dilutional hyponatraemia
…ally consult the available supporting doctor at the clinic; and failure to transfer him to hospital for observation and monitoring of a suspected heat casualty. A quantitative, objective threshold-based heat management …
24y · Male·left intracerebral haemorrhage and consequential brain bleeding resulting from h…
Hendrick Njana, a 24-year-old Aboriginal male, was assaulted on 27 December 2008 by Shaun Steven Midd at a service station in Broome, suffering a strike to the head causing unconsciousness, kicks to the head with steel-c…
20y · Male·head and neck injuries sustained when struck by train
Jordan James Williams, 20, died after being struck by a train following two absconsions from Kalgoorlie Health Campus mental health unit on 24 August 2018. He was involuntarily admitted with first-episode psychosis. Crit…
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