538 results for “observation”
55y · Female·Multiple drug toxicity in a woman with coronary artery atherosclerosis
A 55-year-old woman with complex medical history including chronic pain, previous multiple abdominal surgeries, gastrointestinal disorders, mental health issues including DID, and suicidal ideation died from multiple dru…
42y · Male·Incised injury to the neck resulting in exsanguination and air embolism
…d in clinical notes, and absence of intermediate-level units between mainstream housing and restrictive observation cells to manage high-risk patients safely.
75y · Male·Metastatic prostatic carcinoma
… He was transferred to the prison's Acute Care Unit which provided constant monitoring, regular nursing observations, and supplementary supportive measures. His Advance Health Directive indicated he did not want treatme…
49y · Male·Carbon monoxide toxicity
…ideation triggered by work stress. Psychiatric clinicians conducted comprehensive assessment, overnight observation, and reassessment. Though his wife wanted hospital admission, clinicians discharged him to his brother'…
Male·Multiple injuries due to train over-run (suicide by train)
…mitted to Logan Hospital mental health services. Liam Wright (19) was transferred from the secure Acute Observation Area (AOA) to an open ward on 14 July 2006 despite documented high suicide risk, repeated absconding at…
17y · Male·fatal asphyxia resulting from severe upper airway obstruction secondary to acute…
…ound collapsed at 6:55am and died shortly after. The coroner found the death preventable through better observation protocols, clear escalation policies, and consistent guidelines for patient-controlled analgesia monito…
70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia
…. Postoperatively, there were missed opportunities for earlier recognition of deterioration (inadequate observation frequency, delayed recognition of severe metabolic acidosis, acidosis overnight). Most significantly, t…
17y · Male·Nathan: head injury; Jesse: multiple injuries
…sight within seconds due to speed and fog. Nathan collided with trees approximately 500 metres from the observation point. Jesse died from multiple traumatic injuries including rib fractures and splenic laceration; Nath…
21y · Male·Multiple injuries sustained when struck by a motor vehicle including severe brai…
… highlights failures in truthfulness and the importance of independent evidence (phone records, witness observations, employment records) in determining actual circumstances.
64y · Female·acute subdural haemorrhage sustained after a fall on Ward 4A
…, and appropriate fall prevention strategies were not implemented. Critically, half-hourly neurological observations prescribed after the fall were not performed for almost 2 hours before she was found unconscious. The …
54y · Female·Opioid toxicity (predominantly fentanyl)
…een specialists about pain management plans; implement enhanced monitoring protocols (at least 2-hourly observations) when opioids are started; escalate respiratory depression signs (low oxygen saturation plus vomiting)…
57y · Male·acute subdural haematoma, cause undetermined (could result from trauma, fall, se…
Paul Thompson, aged 57, died from acute subdural haematoma (brain bleeding). He was found unresponsive after an evening of heavy alcohol consumption with his housemate Lawrence Kean, who punched him during an altercation…
38y · Male·multiple injuries
…d schizophrenia died from multiple injuries after jumping or falling from a dam wall while under police observation. He had been recently distressed following his family dog's death, which he had stated would trigger su…
82y · Female·Acute bronchopneumonia
…emperature remained elevated (38-39°C) overnight on 5-6 July. The night nurse RN Delos Santos conducted observations every 2 hours and called an ambulance at 6:30am when fever persisted and medication was refused. The c…
25y · Male·acute bronchopneumonia and methadone toxicity with high body mass index and obst…
Emmett Brown, a 25-year-old First Nations man, died in custody from acute bronchopneumonia and methadone toxicity, with obesity and obstructive sleep apnoea as contributing factors. He had been denied entry to the Buvida…
17y · Male·Subarachnoid haemorrhage caused by penetrating left orbital injury with a long k…
A 17-year-old meat trimmer sustained an unintentional self-inflicted penetrating left orbital injury with a knife while at work, resulting in a subarachnoid haemorrhage (SAH) and death. Despite initial clinical uncertain…
40y · Male·drowning
…n's failed due to manufacturing defect never detected by self-testing. The coroner noted that effective observation was compromised by spotlight use affecting peripheral vision, and that Mr Marriott lacked experience in…
57y · Male·Aspiration pneumonia complicating large bowel volvulus in a man with chronic dys…
…ce directives. After clinical improvement, he was transferred to palliative care at Wantirna Health for observation before returning to disability accommodation. His swallowing was further impaired post-illness. He deve…
47y · Male·Multiple injuries (motor vehicle impact — motorcycle rider)
…inspections by VicRoads and contractors in the preceding weeks. Inspection procedures relying on visual observation from four-wheeled vehicles failed to detect irregularities particularly hazardous to motorcycles. This …
2y · Male·pneumonia in association with bronchiolitis
Child T, a 2-year-old boy in Department of Communities' care, died from pneumonia in association with bronchiolitis on 13 July 2019. The coroner found the Department should have intervened with more intensive family supp…
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