538 results for “observation”
64y · Male·Aspiration event obstruction in a man with oropharyngeal dysphagia and Parkinson…
…ation in patients with known dysphagia and progressive neurodegenerative disease, and consider extended observation or admission thresholds when multiple risk factors coexist.
32y · Female·Hypoxic-ischaemic encephalopathy due to hanging
…cations and experiencing suicidal ideation. Care was clinically appropriate including risk assessments, observations, and medication use consistent with guidelines. She hanged herself using bedsheet over ensuite door on…
8y · Male·Streptococcus pyogenes and parechovirus infection
An eight-month-old boy in state child protection care died from Streptococcus pyogenes and parechovirus coinfection. He presented to regional ED on 2 September with fever and ear infection signs, then 4 September with mi…
86y · Male·head injury (acute intracerebral haemorrhage and subarachnoid haemorrhage)
…ow falls risk (11/20 on FRAT) but then reassessed as medium risk. Despite falls interventions including observation, he had an unwitnessed fall outside his room at 2:35am on day 2, resulting in acute intracerebral and s…
54y · Male·aspiration pneumonia caused by multiple drug toxicity
Paul Lau, aged 54, died from aspiration pneumonia caused by opioid toxicity following ACL reconstruction surgery. The death resulted from a prescribing error where anaesthetist Dr K. inadvertently prescribed a 100mcg/hou…
42y · Male·Upper airway obstruction (choking) in an obese man with atherosclerotic heart di…
Andre Walter Bond, a 42-year-old man with schizophrenia, schizoaffective disorder, Asperger's syndrome, and severe obesity, died from upper airway obstruction (choking) on food while dining at home. He had been recently …
24y · Male·Peritonitis secondary to a perforation of the small bowel
…f life-threatening injury; poor communication between junior and senior doctors; and inadequate nursing observations during one-to-one care. The clinical lesson is that suspected bowel injury requires either immediate e…
29y · Male·Hanging
…prisoners without proper authorization under mental health legislation. Recommendations included hourly observations, CCTV monitoring, formal staff induction, and disclosure of medical information to correctional staff.
89y · Male·Cervical spine trauma
…te it, so transitioned to palliative care. Expert review found his initial post-incident assessment and observation were appropriate, with no immediate indicators for transfer. Key clinical lessons include clarity aroun…
83y · Female·Hyponatraemic encephalopathy due to adverse effects of citaprolam and duloxetine…
…te escalation and communication during clinical deterioration—nursing staff failed to escalate critical observations to senior staff using early warning systems; (5) inter-hospital transfer processes require clear commu…
0y · Female·Pneumonia in an infant with surgically repaired congenital heart disease, premat…
…nd PMH and community nursing via Hospital in the Home. While the HiTH nurse did not perform vital signs observations during a visit on 18 November when the child was unsettled, the coroner accepted this was not substand…
Male·Gunshot wound to the abdomen
Alan Kent Dyer died from a gunshot wound to the abdomen inflicted by Constable Damro during a police response to a house fire and armed person incident on 31 May 2008. Dyer had a history of depression, previous suicide a…
20y · Female·Head injuries sustained in motor vehicle accident
…systemic lessons include: cannabis impairment may not be apparent to clinicians or police officers from observation alone; blood testing protocols must include drug screening for all seriously culpable drivers in fatal …
69y · Female·unascertained
Christine Pearl Stroner, 69, died of an unascertained cause on the evening of discharge following laparoscopic cholecystectomy and hiatus hernia repair at Fremantle Hospital. She was observed at 2pm with tachycardia (HR …
64y · Female·Bilateral pulmonary embolism with left middle cerebral artery/posterior cerebral…
Marlene Kenny, 64, presented to Orbost Hospital on 8 January 2007 with chest tightness, breathing difficulties and low oxygen saturation (83-86%). A doctor diagnosed panic attack and discharged her without investigation.…
72y · Male·Cranial fracture and intracranial haemorrhage from self-inflicted fall
…agitation and behaviours. The fall occurred unexpectedly despite close supervision and 15-minute visual observations. Post-mortem examination confirmed a right parietal fracture with subdural haemorrhage and midline shi…
31y · Male·Gunshot wounds to chest
…ed scenario-based training, recorded interviews of officers involved in such incidents, and independent observation of police interviews.
83y · Female·Complications arising from a fall with C2 fracture and neck of femur fracture
…ient to maintain policy compliance; and documented risks of independent ambulation necessitate constant observation to prevent preventable injuries in vulnerable aged populations.
28y · Male·toxicity to heroin
Michael Anthony, aged 28, died from heroin toxicity in a locked toilet cubicle at the Braybrook Hotel on 8-9 March 2011. He had a 13-year history of heroin dependence, complicated by polysubstance use including methylamp…
59y · Male·Hanging
…ng psychiatric care and antidepressant medication (mirtazapine), he was not assessed as requiring close observation in the weeks before death. He appeared accepting of returning to mainstream population when segregation…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.