402 results for “fall risk”
86y · Male·Traumatic Subdural Haemorrhage
…continued driving the door downward despite the obstruction, causing the door to unspool from its shaft and fall uncontrollably out of its guide channels. The coroner accepted recommendations for design modifications inc…
62y · Male·Head injury sustained in a fall from a vibrating roller that became uncontrollab…
…onal emergency brake created an uncontrollable situation. Contributing factors included lack of formal site risk assessment, informal ad-hoc work arrangement with no supervision, and the operator's assumption that all pa…
45y · Male·subdural haemorrhage sustained in a fall
Benjamin Ware, an intoxicated 45-year-old man, was taken by police to a diversionary centre in Cairns. He vomited several times during the evening and was monitored regularly by staff. The next morning, other clients wok…
85y · Female·Coronary artery disease and heat exposure
…ing behaviour and stated desire to leave but failed to implement additional care strategies, conduct formal falls risk assessment, consult with medical professionals, or involve aged care mental health services. On an ex…
74y · Male·Intra-abdominal haemorrhage complicating elective umbilical hernia repair
…-reliance on a single haemoglobin result to exclude bleeding; failure to recognise that haemoglobin doesn't fall immediately in acute bleeding; inadequate communication from ICU staff about escalating vasopressor require…
31y · Male·Injuries sustained in a fall from height
… follow up the psychiatric referral, poor communication between teams, and inadequate assessment of suicide risk. Clinical lessons include: always complete mental state assessments regardless of initial refusal; ensure c…
73y · Female·neck compression by ligature
…ligature strangulation in a closed psychiatric ward at Glenside Hospital. She had chronic pain since a 2002 fall, depression, and histrionic personality disorder. Two days before her death, she told her son she would be …
95y · Female·Acute intracranial haemorrhage
… assessment, safety planning, and formal protective interventions could have identified and mitigated abuse risk. The coroner found no direct causal link between police failures and death but identified significant syste…
80y · Female·acute subdural haematoma following a fall while on warfarin for atrial fibrillat…
Mrs Bowerman, aged 80, fell at home on warfarin anticoagulation and sustained a minor head injury with no initial neurological signs. Paramedic Turnbull assessed her as requiring no transport (TNR), despite her anticoagu…
20y · Male·Multiple injuries from fall from height
… disorder and anxiety, disclosed suicidal ideation to a prison psychologist. This led to his placement on a Risk Intervention Team management plan requiring isolation in an assessment cell. The subsequent management exem…
59y · Male·Unascertained
…recently been discharged from Royal Melbourne Hospital following treatment for rib fractures sustained in a fall while heavily sedated on diazepam during home detoxification. Key clinical issues included: (1) poor commun…
24y · Male·multiple injuries
…ndrew Seton, an experienced 24-year-old backcountry skier, died on 3 September 2022 following an accidental fall while skiing alone at Watsons Crags in Kosciuszko National Park in icy conditions. He was not reported miss…
16y · Male·Multiple blunt traumatic injuries from fall from height
…Specifically, the treating psychiatrist did not adequately communicate to the patient's mother the specific risk factors—particularly that he had expressed intent to jump from cliffs upon returning home—and failed to dis…
39y · Male·Injuries sustained in a fall from the Camberwell train station bridge
Justin Crome, a 39-year-old man with delusional disorder and schizophrenia, died by suicide after jumping from a railway bridge on 13 February 2020. He had a history of mental illness since 2016, multiple psychiatric adm…
87y · Male·asphyxia due to neck entrapment between bedpole and mattress
An 87-year-old man with dementia and a history of falls died from asphyxia when his neck became entrapped between a bedpole and the mattress after falling from be…
76y · Male·Intracranial haemorrhage
…edication chart, consult applicable guidelines, or escalate 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 di…
46y · Male·gyroplane crash resulting from hub-bar failure in flight
…ss during service. The coroner found critical gaps in regulatory oversight: commercial gyroplane operations fall outside the recreational aviation regulatory scheme managed by ASRA, leaving them regulated by CASA without…
79y · Male·Urinary tract infection with E coli bacteraemia on a background of ischaemic hyp…
A 79-year-old man with multiple comorbidities attended Whyalla Hospital ED following a fall. Paramedics documented concerning vital signs (tachypnoea, tachycardia, low oxygen saturation, fever) and a…
61y · Male·Hypoxic encephalopathy arising from cardiac arrest following self-removal of a c…
…een medical and nursing staff regarding CVC removal; (3) lack of monitoring for delirium despite recognised risk; (4) delayed CVC removal in the ward setting increased air embolism risk. St Vincent's Hospital implemented…
28y · Female·Multiple injuries sustained in a fall from height
… a 28-year-old with schizoaffective disorder and polysubstance abuse, died from multiple injuries sustained falling from an overpass after absconding from Sunshine Hospital's emergency department. She was released from c…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.