332 results for “emergency patient transfer”
31y · Male·Complications in association with intestinal volvulus
…wing afternoon, he was critically unwell with intestinal volvulus, sepsis and pneumonia. He died despite emergency surgery preparation. Key failures included: absence of supporting care worker at initial ED visit, inade…
36y · Male·infective endocarditis
…ncess Alexandra Hospital general medicine was triaged as non-urgent (category B, 30-day appointment). The patient deteriorated rapidly in late May with pneumonia and cardiac failure, requiring emergency hospital transfe…
85y · Male·intracerebral haemorrhage due to systemic hypertension with coronary artery athe…
…itable given the extensive haemorrhage and his age, even with earlier response. However, earlier hospital transfer would have provided palliative care and family presence. The inquest examined police CAD (Computer Aided …
36y · Male·Drowning
…ent and inadequately communicated risk assessments among clinical staff; failure to physically search the patient or remove his car keys despite acute suicide risk; and inadequate supervision—the patient was left unsupe…
67y · Male·Aspiration of vomit associated with alcohol intoxication in a man with ischaemic…
…r aspirating vomit while heavily intoxicated with methylated spirits. He presented to Northam Hospital's Emergency Department and was assessed by nursing staff but not formally reviewed by a doctor. Nurses determined he…
48y · Female·Acute respiratory failure (cerebral hypoxia) in a woman dependent on non-invasiv…
…bleshoot the equipment failure. Key clinical lessons: disability support workers caring for NIV-dependent patients require structured, accredited training beyond brief 'train the trainer' approaches; new backup ventilat…
56y · Male·complications of metastatic colorectal carcinoma
…old experiencing homelessness, died from complications of metastatic colorectal carcinoma. He made three emergency calls over two days before his death, but ambulances did not attend the first two calls. Key issues incl…
84y · Female·left lower lung bronchopneumonia in conjunction with small distal pulmonary embo…
An 84-year-old woman with comorbidities sustained right shoulder and pelvic fractures from an accidental fall. She presented to ED with low oxygen saturation (77%) requiring supplemental oxygen. Despite these injuries an…
32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity
A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with …
53y · Male·severe burns
…ls, poor inter-agency communication, police not contacting triage, hospital staff not securing section 10 patients, and use of highly flammable OC spray in context of fuel exposure. Coroner determined cause as severe bu…
16y · Female·consequences of acute asthma with hypoxic encephalopathy
…of asthma. Key clinical lessons: (1) asthma was provisionally diagnosed but never clearly communicated to patient/family by Dr I. (30 March) or Dr J. (12 April and 3 May); (2) no lung function testing (spirometry or pea…
55y · Male·Hanging
Peter Tully, 55, died by hanging 4 days after discharge from his first psychiatric admission for major depressive disorder with suicidality. He had made 3 suicide attempts in the week before admission. During hospitalisa…
34y · Female·multiple drug toxicity
…without regular case management following her previous case manager's departure in November 2016, delayed transfer to a new community mental health team, and suboptimal discharge planning from the November 2016 admission…
29y · Female·peritonitis caused by ischaemia of the bowel due to gastrointestinal torsion (tw…
…iple levels: carers at her group home delayed calling an ambulance despite hours of severe distress, the emergency department misclassified her triage category (Category 3 instead of Category 2), she was left on an ambu…
47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…
…a Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-dos…
28y · Male·Gunshot wounds of the neck, chest and abdomen
…mpliant demeanor created false security, leading Richardson to leave him unsupervised. Better information transfer, mandatory QPrime checks before guarding duties, continuous risk reassessment, and maintaining handcuffs …
68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…
…2019, a respiratory registrar attempted to prescribe discharge apixaban but mistakenly ordered it as an inpatient medication, then cancelled the wrong order, leaving both medications active. The patient received both dr…
24y · Male·0.22 calibre gunshot wound to the head (self-inflicted)
Christopher Merritt, a 24-year-old man with a history of reactive depression triggered by relationship breakdowns, presented to his GP Dr W. on 30 June 2003 with acute tearfulness, suicidal ideation, and dangerous reckle…
71y · Female·multiple pulmonary thromboemboli and deep vein thrombosis
…s delayed due to absent pathology results, unfamiliar ordering systems, and lack of radiographer on-site. Patient remained ramped (in ambulance) for 8 hours due to full ED and no available beds. She arrested and died be…
76y · Male·Intracranial haemorrhage
…calate to hospital. A severe headache (9.5/10) after a fall with head trauma in an anticoagulated elderly patient warranted urgent hospital transfer; instead he was discharged after 95 minutes observation. He deteriorat…
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