538 results for “observation”
16y · Male·drowning
A 16-year-old male exchange student died from drowning while free-diving at Lighthouse Bay, South Bruny. His foot became entangled in spear gun line after he dove to retrieve his spear, which had become wedged between ro…
42y · Female·Incised injury to the neck
…ile admitted to a psychiatric inpatient unit. She had been assessed as low risk and placed on 30-minute observations. Clinical management of her depression was reasonable, with appropriate medication adjustments and fam…
45y · Male·unascertained
Mark Anthony Theakston, a 45-year-old man with severe intellectual disability and autism residing in supported accommodation, died of an unascertained cause on 25 May 2008. He had collapsed on 21 May with a syncopal epis…
33y · Male·Postural asphyxia due to restraint (Posey Poncho vest)
…on and need for frequent monitoring were never provided to staff despite being supplied with equipment. Observations were inadequate and no formal management plan documented. The coroner identified key system failures: …
7y · Female·Group A Streptococcus (Streptococcus pyogenes) pneumonia with sepsis
… paramedics did not consult these protocols. The decision not to transport was a missed opportunity for observation and assessment. Contributing factors included paramedic fatigue from extended shift patterns, insuffici…
20y · Male·ligature compression of the neck (hanging)
Isiah Kearing, a 20-year-old Aboriginal man, died by hanging approximately 3 hours after being arrested by police for disorderly conduct at a community hall. He had expressed anger and humiliation about being arrested, f…
44y · Female·Combined drug toxicity (elevated pregabalin, temazepam, oxazepam, ibuprofen, mel…
Caitlin-Lei Alaya, a 44-year-old woman with fibromyalgia, PTSD, depression and suicidal ideation, died from combined drug toxicity (elevated pregabalin, temazepam, ibuprofen, meloxicam). She survived a suicide attempt on…
34y · Male·hanging
…tention in clinical decision-making. The coroner found discharge was not justifiable and that continued observation would have prevented this death.
64y · Male·plastic bag asphyxia
…about his suicide risk, he was transferred from intensive psychiatric care to an open ward on 15-minute observations. He created a dummy in his bed to avoid detection while he self-asphyxiated in his bathroom using a la…
78y · Male·cardiorespiratory failure due to complications of tracheal stenosis
…vital sign calling criteria were inappropriately implemented and inadequately reviewed; (2) Respiratory observations were inconsistently recorded, missing opportunities for escalation; (3) The critical airway narrowing …
46y · Male·Ventricular arrhythmia in a man with epilepsy and documented episodes of bradyca…
…nsure medical files and medication doses accompany prisoners during transfer, and consider higher-level observation for patients with acute medication instability. However, the coroner found monitoring would not have pr…
44y · Male·Cardiomegaly
Lionel Perry, a 44-year-old Aboriginal man with schizoaffective disorder and polysubstance abuse history, died from cardiomegaly (enlarged heart due to concentric ventricular hypertrophy) while an involuntary psychiatric…
1y · Male·Septicaemia due to Streptococcal (Beta Haemolytic Group A) infection
Troy Almond, a 17-month-old boy, presented to the Emergency Department with fever, lethargy, vomiting, and tachycardia. Vital signs showed heart rate 173 bpm (red zone) and fever 38.9°C. Dr T. diagnosed viral illness (po…
77y · Female·Subdural haematoma secondary to blunt head trauma (head-strike)
A 77-year-old woman on warfarin for atrial fibrillation presented to Sandringham Hospital after striking her head on a wall. Despite being on anticoagulation therapy, no CT scan was performed, and she was discharged afte…
82y · Male·Ischaemic heart disease due to coronary atherosclerosis with significant contrib…
…ailed to read his Risk Intervention Team management plan, failed to conduct required 60-minute physical observations, failed to respond appropriately to alarm activation and a 105-minute period where he lay unattended o…
57y · Female·Injuries sustained when struck by a train
Mairi Elizabeth Noble, a 57-year-old woman with a history of alcoholism who achieved sobriety, presented to the Northern Hospital ED twice in the days before her death by suicide. She was discharged prematurely on 21 Feb…
40y · Male·unascertained
…teroids. Despite being on prescribed diazepam, temazepam, quetiapine, and pain medications, and nursing observations every 15 minutes, he was found unresponsive at 5:35 AM. Resuscitation failed. Post-mortem revealed mul…
57y · Male·Multiple Organ Failure and Intra-Abdominal Haemorrhage following Cholecystectomy
A 57-year-old man with multiple comorbidities (obesity, diabetes, hypertension, COAD, sleep apnoea) underwent elective laparoscopic cholecystectomy at a regional hospital. The procedure was converted to open due to dense…
29y · Male·Multiple injuries sustained in a train incident (intentional self-harm)
…Unit on 5 May 2007. Despite being assessed as suitable for the Low Dependency Unit (LDU) with 15-minute observations, he absconded over a 1.4-metre fence on the evening of 7 May 2007 and died by suicide at a railway cro…
48y · Female·Ischaemic brain injury secondary to toxicity to tramadol and temazepam
…ospital for approximately 21 hours. Dr D. provided only telephone advice and a home visit, recommending observation at home rather than hospitalisation despite the patient being unrousable and unconscious. The coroner f…
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