54 results for “emergency examination order”
27y · Male·multiple injuries after a fall from a height
…m Cowdy Ward mental health facility on 6 October 2004 while an involuntary patient under a 7-day detention order. He had been admitted following an assault charge and was experiencing acute psychiatric symptoms. He was …
33y · Male·Mixed drug toxicity
A 33-year-old man with complex psychiatric history (bipolar disorder, schizoaffective disorder, autism, ADHD) and long-standing substance use disorder died from mixed drug tox…
0y · Unknown·Unascertained
…den infant death. The case highlights challenges in determining cause of death without complete autopsy examination, particularly when natural, accidental, and deliberate causes cannot be excluded.
18y · Male·Hypoglycaemic hypoxic-ischaemic encephalopathy, due to massive liver necrosis, d…
…tic evaluation was delayed, though unlikely to have altered outcome. Systemic failures included failure to order liver function tests when hepatitis diagnosed, lack of structured assessment protocols for antiviral treat…
85y · Female·aspiration of gastric contents following vomiting
…was admitted to the Roy Fagan Centre with psychotic depression and was under a Mental Health Act treatment order. During the week before death, she developed gastrointestinal symptoms including pain and vomiting. GP Ass…
60y · Male·sepsis and aspiration pneumonia in a man with oral squamous cell carcinoma and m…
…ded amending policy to include specific procedures for terminally ill prisoners under continuing detention orders.
38y · Female·multiple stab injuries to the chest and abdomen
…s included: the incident not being recognised as a family violence matter despite an existing intervention order; incomplete information sharing between police and hospital; loss of nursing notes due to system errors; a…
14y · Female·Neisseria meningitidis infection (meningococcal septicaemia)
A 14-year-old girl presented to Gosford Hospital Emergency Department on 4 December 2007 with high fever (40°C), headache, vomiting, myalgia, and haemodynamic inst…
24y · Male·acute hydrocephalus due to undiagnosed colloid cyst of the third ventricle of th…
… catastrophic brain herniation overnight and died in Sydney the next day. The coroner found the failure to order CT scan despite clear red flags—referring doctor's explicit concerns, concerning history, and significant …
62y · Female·subacute subdural haematoma due to a closed head injury sustained in a fall from…
…e her anticoagulated status, recent head trauma, and concerning symptoms, the ED registrar (Dr P.) did not order a repeat CT scan, relying instead on the previous negative report. The patient was discharged home and die…
43y · Male·Hanging
Mathew James Luttrell, a 43-year-old Aboriginal man with borderline personality disorder, chronic suicidal ideation and substance abuse, was admitted to Mildura Base Hosp…
4y · Female·consequences of incarcerated congenital left diaphragmatic hernia
…on investigating obesity and did not adequately consider the vomiting as potentially serious, declining to order abdominal or chest imaging. When presenting to hospital in collapse, she was discharged after brief assess…
26y · Female·sepsis
…is arising from a post-caesarean wound infection caused by MRSA on 22 October 2014. She presented to the Emergency Department on 20 October with severe pain, tachycardia (125 bpm), and fever. Dr P., the obstetrics regis…
39y · Female·Hypovolaemic shock due to incised injury to the wrist
…ollowing a suicide attempt involving razor blades and medications. She was placed on a Temporary Treatment Order and her belongings were searched on admission. A Kindle device was not thoroughly examined—the cover was n…
8y · Male·bacterial meningitis that had not been diagnosed by a number of clinicians who h…
Eight-year-old Isaraelu Pele died of bacterial meningitis missed by multiple clinicians despite three hospital presentations and two GP visits between 14–17 December 2007. Critical failures included: inadequate different…
29y · Female·respiratory depression caused by morphine intoxication on a background of upper …
A 29-year-old woman with infectious mononucleosis and severe sore throat died from respiratory depression caused by morphine intoxication with concurrent upper airway narrowing. A GP administered 30mg intramuscular morph…
71y · Female·ischaemic cardiovascular disease
…oncurrent medications were not clinically indicated and their safety profile was concerning, postmortem examination revealed significant coronary artery disease was the probable primary cause of death. Key lessons: medi…
76y · Male·Extensive small bowel infarction caused by superior mesenteric artery thrombus
…nosis should have been considered earlier given the clinical presentation; CT angiography should have been ordered sooner; and there was a 3.5-hour delay between oral and written radiology reporting. Despite emergency t…
59y · Male·Pulmonary embolus
… days of acute onset shortness of breath. The registrar diagnosed COPD based on normal vitals, clinical examination, normal ECG, and chest X-ray showing increased lung volumes. The patient was discharged with outpatient…
gunshot wounds; multiple deaths during police interventions with mentally ill in…
Between October 2003 and February 2006, Queensland police shot and killed four young men suffering from severe mental illness during crisis situations. In all four cases, the shootings were legally justified as the offic…
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