95 results for “clinical instability”
44y · Female·multi-organ failure and polypharmaceutical overdose on a background of severe ch…
…ents initially, her underlying lung disease precluded intubation. She deteriorated and died 4 days later. Clinical lessons include: recognition that patients with chronic illnesses and substance abuse require integrated …
56y · Male·Crush asphyxia (Petrus Jong); multiple injuries with crush asphyxia (Helena Jong…
…was unable to determine definitively whether caravan design defects (inadequate tow ball weight causing instability) contributed to the collision, or whether the Ford Explorer's movement into the truck's path resulted f…
0y · Male·complications of extreme prematurity in the setting of precipitant premature bre…
…treme prematurity combined with being born outside a tertiary centre without adequate antenatal steroids. Clinical lessons include: recognising early signs of cardiovascular compromise (persistent tachycardia, metabolic …
17y · Female·self-inflicted hanging
…anning, poor information sharing between DCF and her psychologist, lack of formal diagnosis despite clear clinical need, absence of substance abuse referral, and no integrated approach to her care. However, her capacity …
60y · Male·Ischaemic gut secondary to superior mesenteric artery dissection complicating in…
A 60-year-old man with severe coronary artery disease presented with acute myocardial infarction, requiring emergency stenting and subsequent bypass surgery. An intra-aortic balloon pump (IABP) was inserted for haemodyna…
44y · Male·Gunshot wound to the head
…ase highlights systemic failures in the firearms licensing regime regarding mental health monitoring. Key clinical lessons include: the importance of documenting behavioural changes and mental health deterioration in med…
32y · Female·Alcoholic ketoacidosis
… structured community care unit but struggled after discharge to independent supported accommodation. Key clinical lessons: (1) complex dual-diagnosis patients require more integrated, coordinated care rather than compar…
59y · Male·Aspiration pneumonia and non-ST elevation myocardial infarction in a man with in…
… was admitted under cardiology. Despite MET calls for deteriorating oxygen saturations and haemodynamic instability, clinical management included antibiotics and supportive care. Goals of care discussions with family pr…
17y · Female·Neck compression by hanging (suicide)
…ent mental health supports (not culturally safe), inadequate support for carers, and repeated placement instability. The coroner identified systemic issues including underfunding of Aboriginal-led services, insufficient…
6y · Unknown·Head injuries sustained from impact by a large falling branch from a gum tree
…ately 30 metres during fine weather, following periods of rain and high winds days earlier. No medical or clinical intervention could have prevented this outcome. The coroner emphasised that while tree-fall incidents are…
46y · Male·Undetermined
…could not establish sufficient evidence of intentional self-harm versus accidental death or other causes. Clinical lessons include recognising vulnerability in socially isolated individuals with substance abuse, untreate…
52y · Female·Aspiration pneumonia complicating end-stage dementia
…continued to deteriorate. Planned transfers to nursing home and palliative care were abandoned due to her clinical instability. The coroner found no basis to criticise her care. The case highlights the poor prognosis of …
76y · Female·multisystem organ failure due to or as a consequence of ischaemic small intestin…
…rgery. However, junior medical staff (surgical registrar and ICU registrar) failed to recognize Mrs MDF's clinical deterioration despite progressive metabolic acidosis and haemodynamic instability over several hours. Cri…
79y · Female·subdural haematoma following mechanical fall with head strike
…isk appropriately assessed at level two requiring one-staff assistance. While the patient's progressive instability and peripheral neuropathy increased fall risk, the coroner accepted expert opinion that falls in elderl…
56y · Male·Multiple injuries sustained in a motor vehicle incident (driver)
…nd restarted antidepressants. Five weeks later, he remained in early medication phase with ongoing mood instability. Post-mortem examination revealed Stage II chronic traumatic encephalopathy (CTE) from 20 concussions s…
38y · Male·acute on chronic right hemisphere subdural haematoma
…he early hours of 30 December while intoxicated, causing re-bleeding from the chronic subdural haematoma. Clinical lessons include the vulnerability of patients with chronic subdural haematoma to minor trauma, the compou…
49y · Male·Multiple injuries from a fall from height
…e was assessed as denying suicidal ideation and appeared calm to multiple clinicians and police. Critical clinical lesson: Patients in acute manic relapse with paranoid delusions, medication non-compliance, and recent su…
53y · Male·Gastrointestinal haemorrhage complicating recent PEG insertion with stroke as a …
…and underwent PEG placement on 6 February 2023. He deteriorated 3 days post-insertion with haemodynamic instability and gastrointestinal bleeding, dying 8 days after procedure. The coroner found no want of clinical mana…
Male
Jarrod Wright died at Liverpool Hospital ICU. He became restless, agitated and clinically unstable but was not placed on 1:1 nursing care as required by existing guidelines. Nursing staff felt …
44y · Male·Unascertained
…e coroner determined he died on or shortly after 4 September 2014, with cause of death unascertained. Key clinical lessons include the importance of structured follow-up after hospital discharge for vulnerable patients w…
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