538 results for “observation”
64y · Male·hypoxic-ischaemic encephalopathy and its complications following cardiac arrest …
…ce impractical. Mr Lens ate alone in his room despite recommendations for dining room meals under close observation. Paramedics removed large unchewed bread pieces from his airway. The coroner found Minda's overall care…
34y · Male·Neck compression by hanging
…ting another prisoner on 21 August 2016, he was initially assessed as high-risk and placed on 15-minute observations. By 23 August, despite minimal change in risk factors, his risk was reduced to low-risk with 120-minut…
1y · Female·infarction and volvulus of the small intestine due to adhesion from prior nephre…
… score of 6 triggered mandatory protocols including senior doctor review within 15 minutes and frequent observations. These protocols were not followed. The child was initially treated in the waiting area without docume…
68y · Female·Coronary heart disease
…: high BNP, new LBBB pattern, prior echocardiographic evidence of wall motion abnormality, and elevated observations including tachycardia (HR>110). The admitting doctor mistakenly believed she had a cardiology appointm…
4y · Male·acute suppurative peritonitis following rupture of an inflamed vermiform appendi…
…ent clinical improvement, normal investigations, and soft abdomen. The child was admitted for overnight observation with planned surgical review the next morning. However, he deteriorated acutely during the night and di…
38y · Male·hanging in custody
Two deaths investigated together: Sandeep Kaur Thind (30F) killed by her husband Ranjit Singh (38M) by strangulation in a McDonald's toilet on 10 August 2013. Singh was remanded in custody and died by hanging in a mental…
54y · Male·compression of the neck due to hanging
Anthony Lanzafame, a 54-year-old remand prisoner, died by hanging in his single cell at Adelaide Remand Centre on 24 May 2016. He had been on remand for 17 months facing murder charges and was undergoing trial when he di…
48y · Male·Coronary artery disease precipitating acute myocardial infarction resulting in c…
…ining. On final admission, high Q-ADDS scores overnight were not acted upon—no medical review occurred, observation frequency decreased despite clinical deterioration, and no consultation with tertiary facilities. These…
29y · Female·global cerebral ischaemic injury in the setting of neck compression
…n 2 September 2015. She had been admitted following a paracetamol overdose and was on 15-minute nursing observations. Despite appropriate psychiatric care, comprehensive risk assessment, and multi-disciplinary planning,…
37y · Male·compression of the neck consistent with hanging
Andrew David Hollonds, a 37-year-old man with personality disorder, substance misuse, and recent psychosis, presented to hospital after a suicide attempt (temazepam overdose) following job loss. He explicitly threatened …
46y · Male·cardiac arrhythmia in a man with coronary arteriosclerosis and myocarditis
Jason Mallett, a 46-year-old man with bipolar affective disorder and schizo-affective disorder, died from cardiac arrhythmia secondary to coronary arteriosclerosis and myocarditis while an involuntary psychiatric patient…
54y · Male·acute myocardial infarction due to coronary artery atherosclerotic disease
…se. Key clinical lessons: patients with recent MI and untreated coronary artery disease require careful observation for recurrent events; chest pain and dyspnoea in a post-MI patient warrant immediate medical evaluation…
63y · Female·bile peritonitis as a complication from a laparoscopic cholecystectomy
… and analgesia without clinical assessment. The coroner found the surgeon was given specific vital sign observations but failed to adequately assess the clinical picture or escalate care. System failures included poor o…
75y · Male·acute right subdural haemorrhage sustained in a fall
…was assessed by GPs who performed neurological examinations, found GCS 15, and discharged him home with observation instructions. Neither GP ordered a CT brain scan despite the high-risk combination of age, anticoagulat…
71y · Male·Positional asphyxia
A 71-year-old man with severe dementia died from positional asphyxia when his neck became wedged in a gate at an aged care facility. He had demonstrated multiple escape attempts within days of admission, with staff docum…
40y · Female·ligature compression of the neck (hanging)
Petra Michelle Marquis, a 40-year-old woman with a documented history of mental health issues including depression, anxiety, PTSD, and borderline personality disorder, died by suicide while in police custody after being …
61y · Male·Pulmonary aspiration of gastric contents (post seizure) due to chronic communica…
… symptoms appear; (2) any unexplained seizure-like episode warrants immediate ambulance attendance, not observation alone; (3) failure to escalate resulted in delayed medical assessment. Early ambulance attendance might…
58y · Male·Hypertensive and valvular heart disease
Kevin McCracken, 58, died of hypertensive and valvular heart disease following sudden cardiac collapse in a prison pre-release unit. He had complex pre-existing cardiac disease including previous valve replacement and ao…
77y · Male·Subarachnoid and subdural haemorrhage post head trauma secondary to a fall
…015, striking his head. Initial assessment by a locum GP found no head injury evidence and neurological observations were ceased. On 30 March morning, Mr Alexander deteriorated with confusion, drowsiness, and inability …
7y · Male·Joshua died due to a combination of physical entrapment of his head which occlud…
…nursing care plan was not documented; the team nursing model created ambiguity about responsibility for observations; and the 10:00pm observations were not performed until 11:10-11:15pm (over an hour late). Joshua was l…
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