332 results for “emergency patient transfer”
32y · Female·Caffeine toxicity
…from multiple system failures: ambulance ramping at hospitals reducing available fleet, inability to warm-transfer the call, absence of welfare check protocols, and high demand on emergency services. The coroner noted th…
46y · Female·hypoxic brain injury due to hanging
…sonality disorder, depression, and cannabis dependence died by suicide while an involuntary psychiatric inpatient. She had previously expressed suicidal ideation including specific plans to hang herself. Key failures in…
53y · Female·sepsis and multiple organ failure attributable to infarction/necrosis of small b…
…the diagnosis was not made for 25+ hours. The CT scan at 9:00 AM failed to identify the occluded SMA. The patient underwent a non-diagnostic laparoscopy at 6:00 PM. Diagnosis was made at a radiology meeting at 8:30 AM o…
23y · Female·complications of ruptured ectopic pregnancy with massive intra-abdominal haemorr…
A 23-year-old woman with a ruptured ectopic pregnancy at a rural hospital required urgent transfer to a tertiary centre. The initial response was classified as routine, and the first ambulance crew arrive…
51y · Female·Multiple injuries sustained from a fall from the top floor of a multi-storey car…
…ne Painter, aged 51, died from multiple injuries sustained jumping from a multi-storey carpark while an inpatient at Royal Perth Hospital (RPH). She had severe treatment-resistant schizoaffective disorder, command hallu…
34y · Male·hanging
…sues, died by hanging on 3 March 2017. Six days prior, he had voluntarily discharged from a psychiatric inpatient unit. On the day of death, he presented to the ED reporting suicidal ideation, then attended a psychiatri…
33y · Female·Hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiop…
…d gross fluid and sodium overload despite evident signs including pulmonary oedema and ascites, premature transfer from ICU to ward despite objections from treating teams with breakdown in communication, and failure to r…
69y · Female·Asphyxiation consistent with hanging
…dividual investigations were appropriate, two critical failures occurred: (1) Dr A. did not recognize the patient's highly changeable mood as a major suicide risk factor and made no documented plan for ongoing psychiatr…
69y · Female·Septic shock due to biliary peritonitis as a consequence of laparoscopic cholecy…
…bile leak complications after laparoscopic cholecystectomy. Critical failures included: (1) inappropriate transfer to low-dependency unit on post-op day 1 despite consultant's undocumented concerns; (2) failure to initia…
74y · Female·Diabetic ketoacidosis
…ommendation; poor documentation of clinical assessments; and crucially, failure to ensure timely hospital transfer despite medical deterioration. The patient refused transfer on three occasions, but experts found her dec…
55y · Male·Multi-system failure complicating intra-operative haemorrhage due to inadvertent…
…ror and converted to open surgery, requesting senior surgical assistance, the bowel became ischaemic. The patient was transferred to Albury Hospital ICU then St Vincent's Hospital where vascular surgeons attempted SMA r…
78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…
…espite being classified as ASA 4 (unsuitable for day surgery). The hospital was licensed only for ASA 1-3 patients. The anaesthetist administered high-flow, high-concentration oxygen for over 2 hours, which in a CO2 ret…
41y · Male·large volume thrombotic stroke within the distribution of the right posterior ce…
…e findings. The critical failure was Dr R.'s failure to diagnose stroke on 7 September and arrange urgent transfer to the Stroke Unit at Royal Hobart Hospital. Instead, an MRI was delayed 4 days. When the MRI eventually …
90y · Female·abdominal sepsis complicating perforated diverticular abscess of the sigmoid col…
…arged on 30 October appearing recovered, then re-presented on 31 October with signs of infection. She was transferred to Dandenong Hospital on 1 November but deteriorated rapidly on 2 November, suffering cardiac arrest a…
83y · Male·Ischaemic heart disease secondary to coronary atherosclerosis
…une, 83, died from ischaemic heart disease with coronary atherosclerosis while an involuntary psychiatric patient at Normanby House. He was admitted following assessment for self-neglect and safety concerns, commenced o…
64y · Female·Bilateral pulmonary embolism with left middle cerebral artery/posterior cerebral…
…al stroke caused by a patent foramen ovale allowing a blood clot to cross from right to left circulation. Transfer to tertiary care was delayed over 9 hours due to poor communication between hospital and ambulance servic…
6y · Male·cardiopulmonary arrest on a background of earlier cardiac arrests and resuscitat…
…ltiple cardiac arrests at school on 21 October 2019, initially resuscitated successfully, but died during transfer preparation to a higher-level hospital that evening. Autopsy revealed a coronary anomaly (anomalous aorti…
48y · Male·sepsis and renal failure due to perforated gastric ulcer
…d pyloric ulcer causing peritonitis was not recognised until 9pm when he was found on the floor in shock. Transfer to the surgical centre was delayed until 11:40pm. Emergency laparotomy revealed 3 litres of faecal matter…
37y · Female·asphyxia due to hanging
…lures included: (1) Dr R. did not adequately assess risk by failing to obtain a separate history from the patient's husband before discharge, despite the patient being at an isolated rural location with four young child…
3y · Male·respiratory failure, with spinal muscular atrophy an antecedent cause
…year-old boy with spinal muscular atrophy (SMA) Type 1, died of respiratory failure during inter-hospital transfer. Admitted to Shoalhaven Hospital on 7 September 2014 with pneumonia and severe malnutrition (50% weight l…
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