127 results for “catheter insertion”
72y · Female·Intrathecal toxicity of bupivacaine and morphine
…She was admitted to Ashford Hospital for pain management of pathological pelvic fractures. An intrathecal catheter was correctly inserted but on 20 September 2010, a senior palliative care physician ordered a bolus dose …
36y · Male·Multiple injuries sustained from intentional jump from cliff top
Alexander Albert Steinbrenner, a 36-year-old man with schizo-affective disorder, died from multiple injuries sustained when he jumped from an 11-metre cliff at the Roundhouse in Fremantle on 27 February 2004. He was an i…
59y · Male·Urosepsis and aspiration pneumonia (with Trisomy 21 as underlying condition)
… 12+ months with multiple falls, recurrent respiratory infections, urinary retention requiring indwelling catheterization, and aspiration risk due to swallowing difficulties. Despite occupational therapy input and discha…
86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall
…xt morning with hypoglycaemia, hypoxia and hypotension, a tension haemothorax was identified. Intercostal catheter insertion was attempted but unsuccessful. The coroner recommended improved trauma assessment protocols an…
0y · Female·Perinatal asphyxia
…e been considered earlier; laryngeal mask airway should be considered after failed intubations; umbilical catheter securement technique requires careful attention to prevent blockage. However, expert review concluded Bab…
60y · Male·End stage renal failure
…ney disease requiring dialysis, but repeatedly removed his central line (permacath). After a traumatic reinsertion in March 2013 caused cardiac arrest, radiologists advised no further reinsertion was possible. In May 20…
61y · Male·Hypoxic encephalopathy arising from cardiac arrest following self-removal of a c…
…man, died of hypoxic encephalopathy following a cardiac arrest caused by self-removal of a central venous catheter (CVC) on day 14 post-bilateral lung transplant. The CVC was still in situ despite two documented orders f…
0y · Male·Hypoxic ischaemic encephalopathy complicating peri partum asphyxia
A term neonate died at 3 days of age from hypoxic ischaemic encephalopathy due to perinatal asphyxia. The mother presented in early labour, was initially discharged, then readmitted when labour progressed. Labour progres…
81y · Female·Severe cardiogenic shock complicating cardiac surgery
…radrenaline without consulting the senior intensivist or surgical team, and without inserting a Swan-Ganz catheter to monitor the haemodynamic consequences. The senior intensivist was not present at handover and was not …
41y · Female·Peritonitis following surgical procedure to the urinary bladder, due to infected…
Cheryl Lee Edmiston, a healthy 41-year-old woman, died of peritonitis and sepsis following minor bladder procedures (cystoscopy, hydrodilatation, and biopsy) at Joondalup Health Campus on 14 February 2003. The biopsies w…
76y · Male·morphine toxicity and carcinomatosis
…erdose administered by agency nurse Cornelia Empen. Hedges had two pain management routes: an intrathecal catheter (delivering 2.2mg over 48 hours) and subcutaneous access (as-needed breakthrough pain relief). Empen, wor…
3y · Male·Influenza A infection (Type H3N2)
Aidan Mara, a 3-year-old boy with influenza A pneumonia and hyponatraemia, collapsed and died from cardiovascular failure on hospital day 3. Critical clinical lessons include: (1) distinguishing SIADH from dehydration ea…
0y · Unknown·focal ventricular myocarditis and myonecrosis resulting from migration of a Peri…
…antibiotics treating periorbital cellulitis. Initial placement in the right atrium was confirmed on post-insertion X-ray. However, the PICC line subsequently migrated into the right ventricle, likely after the securing …
79y · Male·multi-organ failure due to voluntary starvation on a background of severe depres…
A 79-year-old man died from multi-organ failure secondary to voluntary starvation in the context of severe depression following his wife's death. He was admitted after police found him malnourished following 30 days of i…
39y · Male·dilated cardiomyopathy
…igh-quality medical management by experienced clinicians, he suffered cardiac arrest during central line insertion and could not be revived. The coroner concluded the death resulted from combined chronic cardiac disease…
20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…
…plete dislodgement. Critically, the tube should have been removed and replaced immediately when a suction catheter could not be passed, but this did not occur for approximately 46 minutes. Staff attempted blind bougie in…
77y · Female·Haemoperitoneum following cholecystectomy
…), failure to check coagulation status until 7:45 pm despite therapeutic anticoagulation, lack of urinary catheter insertion until 8:00 pm, delayed antibiotic administration, and poor inter-team communication and documen…
68y · Female·Haemorrhage secondary to right subclavian artery lacerations sustained during ce…
…sive blood loss following inadvertent puncture of the right subclavian artery during central venous line insertion. The anaesthetist used anatomical landmarks without ultrasound after an initial high approach failed. Up…
5y · Female·Cerebral hypoxic and ischaemic injury in a setting of clinical birth asphyxia
Chloe Kellett was born at 39 weeks gestation after induction of labour for rupture of membranes and group B streptococcus positivity. She was delivered by forceps in theatre for a non-reassuring cardiotocogram (CTG) trac…
61y · Male·Pneumonia
Kenneth Morrison, a 61-year-old man with Down's syndrome, dementia and multiple comorbidities, died from pneumonia following hospitalisation at Casey Hospital in March 2008. Community Residential Unit (CRU) carers raised…
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