88 results for “central monitoring”
44y · Male·Positional asphyxia
…bis caused profound CNS depression; patients with mental illness and substance abuse require coordinated monitoring and safe medication management. The coroner noted concern about clozapine security and prescription supe…
52y · Male·hanging
… quarantine on 11 April 2020. This case highlights critical failures in mental health screening, welfare monitoring, and escalation procedures. Recent personal stressors (marital separation, job loss) rendered him vulner…
61y · Female·Gunshot injury to head
…ced by carboxyhaemoglobin saturation of 42% and cyanide levels. The clinical lesson is the importance of monitoring medication levels and drug interactions in patients on multiple central nervous system depressants, part…
1y · Male·Hypoxic ischaemic encephalopathy
Dean Smith, a full-term neonate, was born severely asphyxiated after an induced labour managed at Central Gippsland Health Service. He died from hypoxic-ischaemic encephalopathy within 24 hours. The coroner foun…
0y · Unknown·focal ventricular myocarditis and myonecrosis resulting from migration of a Peri…
A 10-month-old boy died from myocarditis and myonecrosis caused by migration of a PICC line into his right ventricle. The line was inserted appropriately under general anaesthetic for IV antibiotics treating periorbital …
27y · Male·chest and abdominal injuries from single motorcycle crash
…ne, pregabalin) and illicit substances including opium alkaloids, indicating poppy tea consumption. These central nervous system depressants impaired coordination, reflexes, and perception. The motorcycle had worn tyres…
20y · Female·Undetermined
…986 disappearance and suspected murder of 20-year-old Sharron Phillips. No medical or clinical issues are central to this case. The inquest examined evidence that Raymond Mulvihill, a taxi driver, may have been responsi…
50y · Female·Potentially fatal multiple drug toxicity (oxycodone, mirtazapine, citalopram, cl…
…he coroner found no individual prescriber at fault but highlighted the absence of real-time prescription monitoring as a critical system gap enabling preventable polypharmacy deaths.
49y · Female·Intra-abdominal haemorrhage, septic and haemorrhagic shock as a result of a lapa…
…n acutely unwell patient; delay in operating until bowel perforation occurred; inadequate post-operative monitoring and failure to recognise and treat internal bleeding despite clear clinical signs; and poor medical lead…
66y · Female·Complications following paracetamol overdose
…mit single packages unless exceptional circumstances exist, and be alert to pharmacy shopping. Real-time monitoring of OTC codeine sales and enhanced warning labels about paracetamol toxicity could prevent similar deaths…
Male·Multiple injuries sustained from aircraft in-flight break-up and ground impact
…ulatory and operational failures: absence of operator oversight for limited-category aircraft, no flight-monitoring or search-and-rescue protocols for non-return contingencies, and absent emergency locator beacons. The c…
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…
38y · Female·mixed drug toxicity (lethal level of dothiepin, potentially lethal level of morp…
…pines and tricyclic antidepressants with ongoing heroin use significantly increased overdose risk through central nervous system and respiratory depression. Key clinical lessons: GPs managing poly-substance users should…
32y · Male·Mixed drug toxicity (codeine, methadone, alprazolam, diazepam) in a man with cor…
… a Prescription Shopping Program with thresholds too high to detect his activity. Real-time prescription monitoring was unavailable. The coroner identified systemic failures in benzodiazepine prescribing practices, monit…
22y · Male·Mixed drug toxicity (tapentadol, clonazepam, citalopram, amphetamine, olanzapine…
…tion shopping. Three general practitioners failed to check SafeScript (Victoria's real-time prescription monitoring system) before prescribing monitored medications, perpetuating his addiction cycle. His regular treating…
37y · Male·Mixed Drug Toxicity (Oxycodone, Quetiapine, Pregabalin and Clonazepam)
… failure. The coroner found the death readily preventable with appropriate pharmacological knowledge and monitoring. Hospital implemented substantial improvements including new monitoring equipment, dedicated staff alloc…
41y · Male·heart failure related to exsanguination due to traumatic rupture of an arteriove…
…ist Dr M.'s care following successful kidney transplant at Royal Melbourne Hospital in December 2015. The central issue was whether Dr M. should have referred him for urgent vascular surgery when examining his fistula o…
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
… 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadequate urine output monitoring (no urinary catheter despite critical illness and acute kidney injury); delayed and sub-optimal antibiot…
68y · Female·Massive blood loss due to disconnection of haemodialysis machine
…ailure of pressure-based alarm systems to detect disconnection, and absence of independent physiological monitoring. The coroner identified system and equipment design failures and made recommendations for safety improve…
49y · Female·stab wound to the neck
…ice (LEAP/PTMI systems), corrections, child protection, and family violence services; the FVIU's passive monitoring rather than proactive victim engagement despite Fairhall being classified high-risk; lack of coordinated…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.