577 results for “medication monitoring”
24y · Male·seizure (epileptic)
…ing his death. He was held in immigration detention for over 2.5 years. Critical clinical lessons: (1) A medication dispensing system failure meant his missed doses of essential anti-epileptic medication went undetected …
45y · Female·terminal epileptic seizure
…, and epilepsy, died from a terminal epileptic seizure with aspiration pneumonia. She received incorrect medication on 7 May 2012 by a support worker; a GP and neurologist assessed her and advised monitoring. While the m…
31y · Male·Hypoxic encephalopathy caused by neck compression due to hanging
…ic encephalopathy following hanging in a prison mental health unit. Despite being psychotic and refusing medication, he was not transferred to a specialised mental health facility (MHSU at Silverwater) for three weeks af…
27y · Male·Cause of death cannot be determined; most likely cardiac arrhythmia in the setti…
… Order died of unknown cause, most likely cardiac arrhythmia. He had appropriate community mental health monitoring including regular appointments, medication administration, and ECG/echocardiogram surveillance. After in…
53y · Male·Neck compression in the circumstances of hanging
…linical improvement, inadequate handover to his general practitioner lacking essential information about medication duration, dosing history, monitoring requirements, and escalation pathways, and lack of consultant psych…
Female·early bronchopneumonia complicating combined drug toxicity (fentanyl overdose)
…ons include: fentanyl should not be initiated at doses >25mcg/h in non-opioid-tolerant patients; careful monitoring is essential in patients with prior drug abuse; warnings about heat exposure must be given; and close ad…
15y · Male·multiple blunt force injuries as a result of being hit by a train
…l ideation, and his mother was not informed that he had expressed suicidal thoughts or given guidance on monitoring for adverse effects. Guidelines available at the time (2009) recommended such warnings and monitoring. A…
32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity
…astric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with sedating effects. The coroner identified multiple deficiencies in care: an inadequate visual obser…
36y · Male·mixed drug toxicity
Justin Blade Stewart, a 36-year-old man with a long history of schizophrenia managed with antipsychotic medications, died from mixed drug toxicity. He was found deceased at home after sleeping overnight. Toxicology reve…
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.
29y · Female·Effects of multiple injuries sustained when she projected herself from the top o…
…or bipolar disorder; ensure comprehensive information-sharing between practitioners; warn patients about medication side effects; involve family in monitoring.
33y · Male·Mixed drug toxicity (heroin, buprenorphine and benzodiazepines)
…to restrict access. Critical clinical lessons: (1) Multiple prescribers failed to identify or act on his medication-seeking behaviour despite warnings from his mother; (2) He declined hospital admission after an overdose…
44y · Male·mixed drug toxicity
Michael Allan Steer, aged 44, died from mixed drug toxicity after ingesting excess prescription medication (quetiapine, codeine, diazepam, fluoxetine). He had complex psychiatric history with factitious and soma…
36y · Male·Combined drug toxicity (pregabalin, morphine, amitriptyline)
…lin, morphine, amitriptyline). His general practitioner, Dr S., prescribed excessive amounts of multiple medications significantly exceeding clinical directions—pregabalin at 1430mg daily (three times directed dose), oxy…
31y · Male·Quetiapine toxicity in a man consuming sertraline and mirtazapine
…rated between October-November 2006. Critical learning: His team relied solely on patient self-report of medication compliance despite documented non-compliance (retrospective pill counts showed he stopped lithium and va…
26y · Male·Craniocervical injuries following a train collision (pedestrian)
…been hospitalized for extended rehabilitation and clozapine management. Clinical lessons include: patchy medication adherence (clozapine) contributed to ongoing psychotic symptoms and suicidal ideation; smoking affected …
47y · Male·abnormal heart rhythm (arrhythmia) induced by atherosclerosis, occurring in the …
…severe coronary atherosclerosis, sleep apnoea, and morbid obesity, while receiving multiple psychotropic medications. Key clinical lessons: his medical conditions were insufficiently monitored despite significant risk fa…
64y · Male·Complications of eosinophilic asthma with bronchiectasis and allergic bronchopul…
…ns include: oxycodone and benzodiazepines are dangerous in patients with severe asthma and sleep apnoea; medication compliance was a concern (missed dupilumab doses); and monitoring gaps existed during the COVID-19 perio…
51y · Male·combined effects of dilated cardiomyopathy with myocardial fibrosis and prescrip…
… sleep observations documentation failed to record respiratory status as required by policy; (3) cardiac monitoring protocols were actually exceeded standards; (4) the combination of antipsychotic cardiotoxicity, undiagn…
32y · Male·overdose of a combination of chlorpromazine, mirtazapine, and diazepam
… ongoing paranoia and suicidal ideation, he was discharged to his mother's care with verbal advice about medication storage. The deceased concealed the severity of his paranoia during a home visit by his case manager. Cl…
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