108 results for “blood test”
4y · Male·acute suppurative peritonitis following rupture of an inflamed vermiform appendi…
… confirmed diagnosis of appendicitis in preschool children is exceptionally difficult; there is no specific test, many mimicking illnesses are more common, and rapid perforation can occur without clear warning signs. The…
32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome
…P prescribed lithium at an incorrect dose (1250mg instead of 1000mg) for three months and failed to repeat blood tests despite elevated lithium levels and signs of dehydration; hospital teams lacked communication betwee…
27y · Female·Aspiration of gastric contents associated with persistent vomiting following gas…
…(2.5), poor communication between her GP and surgeon led to premature discharge without review of critical blood results. She subsequently collapsed at home and aspirated, dying despite resuscitation. Key failures inclu…
88y · Female·Acute on chronic renal failure due to dehydration on a background of Lewy body d…
…e cardiac failure died from acute kidney injury precipitated by severe dehydration in aged care. June 2020 blood tests showed mild hypernatraemia (sodium 149 mmol/L), a biochemical marker of dehydration risk, but this w…
64y · Male·hypoxic-ischaemic encephalopathy complicating cardiac arrest due to retroperiton…
…enoxaparin (100mg twice daily) initiated under an orthopaedic protocol. Critical failings included: (1) no blood tests performed after admission to monitor haemoglobin or renal function despite therapeutic anticoagulati…
8y · Male·bacterial meningitis that had not been diagnosed by a number of clinicians who h…
… signs (lethargy, fever, headache, persistent vomiting, pallor), and failure to perform lumbar puncture or blood cultures. Paracetamol appeared to improve symptoms, falsely reassuring clinicians. The coroner found the d…
45y · Female·Extensive retroperitoneal haemorrhage following bone marrow biopsy procedure wit…
…risk), and monitoring. Recommendations addressed imaging-guided biopsy, expedited notification of abnormal blood results, and complete recording of observations.
77y · Female·haemorrhagic diathesis due to warfarin toxicity
…al hospital. She had a prosthetic aortic valve requiring anticoagulation. INR monitoring was inadequate: no tests for 36 days (July 28–September 2), then readings of 8.9, 1.2, 8.1, and finally 12 before death. The visiti…
72y · Male·Subarachnoid haemorrhage in a man with coronary arteriosclerosis
Ilija Kocovski, a 72-year-old man with a history of ischaemic heart disease, presented to Royal Perth Hospital Emergency Department on 22 October 2000 with chest pain, nausea, vomiting, and headache after arriving in Per…
64y · Male·Postoperative intra-abdominal bleeding from pancreatic artery injury and its con…
… that was not recognized initially. The anaesthetist incorrectly diagnosed anaphylaxis and failed to order blood tests, though he sought ICU input. The surgeon waited for results but then prioritized another patient's o…
11y · Female·Complications of E. coli sepsis in association with intestinal obstruction due t…
…2017 with severe abdominal pain and vomiting. She died 12 hours later from E. coli sepsis associated with intestinal obstruction due to faecal impaction of megacolon. Critical delays in management included: a three-hour …
35y · Male·Acute Staphylococcus aureus Meningitis
Christopher Nigel Spinks, a 35-year-old tree surgeon, died of acute Staphylococcus aureus meningitis on 3 December 2002. He initially presented on 27 November 2002 with neck pain following a windsurfing accident. Dr R. n…
56y · Male·pulmonary thromboembolism due to left deep vein thrombosis
… that application of standardised PE evaluation criteria (Wells score and PERC) would have mandated D-dimer testing given the patient's age >50 and heart rate >100 bpm. A positive D-dimer would likely have led to urgent …
5y · Female·myocarditis
…both the registrar and consultant paediatrician; lack of allocated responsibility for following up troponin test results; failure of ICU to properly assess the critically ill child despite consultation; inadequate handov…
67y · Male·Fulminant liver failure
A 67-year-old man presented to his GP with discoloured urine. Blood tests revealed acute liver toxicity but critical results were communicated via facsimile, with unclear tim…
39y · Male·cardiomegaly
…assessment on admission included ECG showing sinus tachycardia attributed to dehydration, chest X-ray, and bloods. Close observations continued until he was found unresponsive at 4:35am. Resuscitation efforts were satis…
2y · Male·Perinatal asphyxia leading to cerebral anoxia and subsequent multi-organ failure
…old. Critical clinical lessons emerged regarding neonatal assessment: persistently pale newborns with cord blood pH 7.02 and hypothermia require investigation for anaemia and foetal-maternal haemorrhage, and repeat bloo…
33y · Female·multiple organ failure complicating sepsis in a woman with cirrhosis of the live…
…ation. A psychiatrist's July 2010 recommendation for liver assessment was received but resulted in delayed blood tests that were never completed before her transfer between prisons. On 13 September, she presented with n…
72y · Male·Multiple organ failure due to sepsis caused by abdominal adhesions from previous…
…hesions and possible pancreatitis (lipase 1080 U/L post-op). Key clinical lessons: (1) pre-operative lipase testing was not completed due to insufficient sample—this would have supported pancreatitis diagnosis; (2) patie…
86y · Female·right subdural haematoma due to blunt head trauma with contributing excessive wa…
…ardiologist on 19 December 2012 for atrial fibrillation, but her INR was never monitored between an initial test (INR 1.9) on 21 December and her death on 5 January (INR 12). Critical failures included: the cardiologist'…
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