89 results for “blood pressure monitoring”
47y · Male·abnormal heart rhythm (arrhythmia) induced by atherosclerosis, occurring in the …
…ly recommended CPAP device was not provided. Better coordination of cardiac and psychiatric care, closer monitoring of vital signs and physical examination findings, and judicious medication selection could have identifi…
91y · Female·traumatic subarachnoid haemorrhage and acute and chronic subdural haematoma as a…
…, provided regular tea despite dietary restriction, and did not immediately recheck a dangerously elevated blood pressure (203/74). The coroner found the nurse's evidence unreliable and criticized her professionalism. T…
77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…
…comorbidities; (3) ICU consultation should have occurred during weekend deterioration; (4) central venous pressure monitoring would have guided fluid management more accurately; (5) consultant cardiologist on-call should…
69y · Female·Urosepsis secondary to anuric acute renal failure and corona radiata infarct; co…
…). Despite clear warning signs of developing sepsis over 19 hours—including progressive falls in diastolic blood pressure, widening pulse pressure, tachycardia, and family concerns—no escalation to medical review occurr…
49y · Male·combined drug toxicity
…While the coroner found his care reasonable overall, the finding identifies that greater physical health monitoring should have been implemented when Karl was prescribed atomoxetine alongside paliperidone, including ECG,…
43y · Male·Multi-organ failure with coagulopathy secondary to acute exacerbation of chronic…
…ay, he deteriorated with worsening headache, vomiting, and nausea—classic signs of increased intracranial pressure. The neurosurgeon rescheduled surgery for Sunday morning but the patient suffered cardiac arrest at 4am S…
86y · Male·multi-organ failure due to sepsis on a background of sacral pressure ulcer
An 86-year-old man died from multi-organ failure due to sepsis from a stage 4 sacral pressure ulcer after 61 days in a regional hospital. Critical failures included delayed pressure injury risk asses…
87y · Female·Pulmonary artery rupture complicating pulmonary artery catheter insertion in a w…
…ypass surgery. A Swan-Ganz pulmonary artery catheter (PAC) was inserted pre-operatively for haemodynamic monitoring. Approximately 45 minutes later, at anaesthetic induction, moderate blood was observed in her oral cavit…
46y · Female·Shock following interferon alpha treatment following removal of a melanoma
… failures included: inadequate vital sign observations despite Between the Flags policy requiring hourly monitoring in a Category 2 patient; failure to document observations and maintain fluid balance charts in a patient…
62y · Female·Multi-organ failure due to lacerated abdominal aorta complicating laparoscopic b…
…t the start of the procedure. Although the surgeon conducted a careful survey for bleeding and found none, blood was lost into the retroperitoneum, which remained undetected for over four hours. The anaesthetist noted p…
62y · Female·Acute bacterial peritonitis and pneumonia
…undermining credibility. Post-operative failures: Despite deteriorating vital signs (oxygen saturation and blood pressure) and persistent vomiting on discharge day (26 Feb), she was inappropriately discharged home. Nurs…
35y · Male·Cardiorespiratory arrest in the setting of acute agitation and physical and chem…
… restraint. He was held prone with hands cuffed behind him, a shield on his back, and additional downward pressure applied, initially in the bathroom for over six minutes, then positioned upright when moved outside. Post…
0y · Male·cardiac arrhythmia associated with surgically corrected congenital heart disease
…ntact a doctor despite alarming vital signs, instead advising parents to take the baby home with minimal monitoring instructions. The baby deteriorated overnight and died the following morning. The Coroner found that imm…
2y · Male·Group A beta Haemolytic Streptococcal septicaemia (invasive Group A Streptococca…
…rm the tachycardia; failure to examine and reassess after petechial rash appeared; and not taking baseline blood pressure until 8pm. Although antibiotics were eventually ordered at 8.30pm, there was a two-hour delay bef…
49y · Male·Obstructive sleep apnoea, contributed to by the sedating effects of therapeutic …
…OSA exacerbated by sedating medications and coronary atheroma. Critical deficiencies included inadequate monitoring of a patient with OSA after benzodiazepine administration, poor record-keeping, and lack of continuous v…
75y · Female·hypovolaemic shock following uncontrolled blood loss from mini-liposuction stem …
…cumented use; inadequate pre-operative assessment; failure to recognise haemodynamic instability (dropping blood pressure, rising heart rate); premature discharge rather than emergency hospital admission; and inadequate…
68y · Female·Massive blood loss due to disconnection of haemodialysis machine
Judith Heath, age 68, died from acute blood loss on 7 September 2006 at The Alfred Hospital during routine haemodialysis for end-stage renal failure. …
Unknown·Ms Fensom: influenza A (H1N1 2009, pandemic swine flu) with myocarditis causing …
…g on 18 August, but the treating registrar (Dr V.) failed to recognise the seriousness of persistently low blood pressure despite it not responding to fluid therapy. Mr Taankink (26), an asthmatic, was prescribed Tamifl…
Female·Combination of liver failure, blood loss and shock following needle biopsy
… was undertaken to investigate potential biliary atresia. Post-operatively, nursing staff could not obtain blood pressure readings (attributed to technical difficulty). When Alyssa deteriorated with low oxygen saturatio…
11y · Male·complications of bowel obstruction in the setting of chronic constipation
…cidosis, and signs of shock. Critical gaps in emergency care included incomplete triage assessment, absent blood pressure recordings throughout ED stay, and placement in an unmonitored room. He was transferred to RCH wh…
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