381 results for “intensive care monitoring”
76y · Male·Coronary atherosclerosis in the context of obesity, obstructive sleep apnoea, an…
…an; (6) chest x-ray findings not reviewed. Patient deteriorated post-operatively with hypoxia but lacked intensive monitoring. Coroner emphasised importance of thorough history-taking, recognition of obstructive sleep a…
77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…
…ies; (3) ICU consultation should have occurred during weekend deterioration; (4) central venous pressure monitoring would have guided fluid management more accurately; (5) consultant cardiologist on-call should have reco…
49y · Male·Hypoxic brain injury following cardiac arrest due to myocardial infarction with …
…ardiac arrest due to acute myocardial infarction with right coronary artery thrombosis while in psychiatric care. He was admitted to the Koori Inpatient Psychiatric Unit at St Vincent's Hospital on 13 January 2017 follow…
48y · Female·Pneumonia with anaphylaxis (treated), cerebral palsy, and epilepsy as contributi…
…potension, which was treated. She deteriorated with deranged liver function and was transitioned to comfort care. The coroner found death from natural causes with no inquest required. Clinically, this case highlights the…
83y · Male·Sepsis due to staphylococcus aureus bacteraemia following infection of a left an…
… essential to prevent catheter-related infections; field-inserted lines require clear identification and monitoring handover; and responsibility assignments must be explicit to prevent oversight. The coroner found this p…
26y · Male·Ligature Compression of the Neck (Hanging)
… including psychotic episodes with delusional beliefs, and a previous suicide attempt. While in psychiatric care at Fremantle Hospital in March 2002, he was discharged without a community treatment order despite expected…
74y · Female·Diabetic ketoacidosis
A 74-year-old woman with Type 1 diabetes died from diabetic ketoacidosis (DKA) in an aged care facility. Between 7-10 December 2016, her blood glucose levels remained persistently elevated (>33 mmol/L) …
69y · Male·asphyxia by hanging
…epression, prostate cancer, and recent suicide attempt was admitted to MAPU (general medical ward) after intensive care treatment. He was deemed low suicide risk and the one-on-one attendant was discontinued. Critical h…
21y · Male·unascertained
…xtensive post-mortem investigation, no definitive cause of death could be determined. The coroner found his care was reasonable given available resources, but identified several system gaps impacting safety: difficulty v…
36y · Female·Complications of pneumonia and pulmonary emphysema with bullae formation; respir…
…e); misinterpretation of respiratory distress as anxiety/alcohol withdrawal; sparse overnight vital sign monitoring despite clinical deterioration; and inadequate resuscitation with no advanced airway management availabl…
73y · Female·Combined effects of congestive cardiac failure, coronary artery atherosclerosis …
…en treated for C. difficile colitis requiring ICU admission for hypotension. The coroner found that medical care was appropriate and the death could not have been prevented. Clinically, this case highlights the challenge…
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…
62y · Male·cerebral haemorrhage (intracerebral bleed, large lobar within left cerebral hemi…
…aled large lobar haemorrhage. The coroner identified significant ED overcrowding that prevented adequate monitoring for 8 hours, though this did not directly cause death. Key lesson: maintain diagnostic humility when ini…
48y · Female·Aspiration of stomach contents and pneumonia, following cardiac arrest
… gastrointestinal bleeding. Clinical management appropriately treated DKA as the primary diagnosis while monitoring for bleeding with serial haemoglobin measurements. A blood transfusion was ordered at 4.45pm when haemog…
68y · Female·intracerebral haemorrhage
… been predicted to have another stroke within five years of her first event. No warning signs were noted by carers or family in the preceding weeks, except for being slightly slower and quieter. She was admitted to ICU a…
45y · Female·Complications of acute alcohol intoxication
…arged from Casey Hospital psychiatry ward on 1 June 2010 while anxious and paranoid. She absconded from her care facility early on 2 June 2010 and purchased methylated spirits, which she consumed. She was found unconscio…
84y · Female·Major cerebral infarct due to hypoglycaemia
…nd bilateral cerebral infarcts. After 8 units of Actrapid insulin at 21:15, no blood glucose level (BGL) monitoring was documented until 5:05 am the next morning when she was found unresponsive with a BGL of 0.8 mmol/L. …
18y · Female·neck compression due to hanging
An 18-year-old female with depression and anxiety was admitted to a psychiatric intensive care unit (PICU) following acute suicidal ideation. Clinically significant issues included: inadequate c…
42y · Female·Global cerebral ischaemia in a setting of anaesthesia
… monitors. Death was preventable with appropriate pre-anaesthetic assessment, functioning pulse oximetry monitoring before and during anaesthesia, and proper airway management. Systemic issues at the facility included po…
50y · Male·Multiple pulmonary thromboemboli due to deep vein thrombosis following pharyngea…
…nued CPAP use despite surgeon and anaesthetist expectations, and absence of continuous oxygen saturation monitoring. The patient suffered undetected hypoxia overnight, leading to respiratory arrest and subsequent thrombo…
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