63 results for “missed approach”
17y · Male·Hypoxic Ischaemic Encephalopathy Complicating Anaphylaxis
…r, adrenaline was administered but he rapidly progressed to cardiac arrest. The coroner identified two key missed opportunities: (1) recognizing the wheeze as recurrent anaphylaxis and immediately alerting a doctor; and …
81y · Female·Cardiac tamponade secondary to dissection of ascending aorta
An 81-year-old woman with hypertension and hypercholesterolaemia presented to the ED with sudden-onset central chest pain radiating to the jaw. Despite appropriate initial assessment and ruling out acute coronary syndrom…
71y · Male·Exsanguination from incised wounds to the neck and wrist
A 71-year-old man with bipolar disorder, depression, alcohol addiction, and cirrhosis died by suicide via exsanguination from neck and wrist lacerations. He had stopped psychiatric medications in 2017 and was managed by …
5y · Male·aspiration pneumonia with terminal palliative care, in a male child with complex…
…Hospital's empathetic end-of-life care. However, the coroner identified that the Department of Communities missed an opportunity in March 2018 to provide intensive family support when the child's mother entered a relatio…
59y · Male·compression of the neck secondary to hanging
…l. The coroner noted this communication failure was unlikely to have prevented his death but represented a missed opportunity for a more comprehensive assessment of his mental state.
23y · Male·Drowning
Stephen John Burt, aged 23, was found deceased in January 1985, with drowning as the cause. His remains were unidentified for 36 years until 2021. Critical failures included: catastrophic incorrect sequencing of fingerpr…
41y · Male·Gunshot and shrapnel wounds to the body (SC Forte); Gunshot wound to the chest a…
…ic gunfire incidents in the area, poor inter-agency communication between Gatton and Toowoomba police, and missed opportunities to locate Maddison before the fatal encounter. While officers complied with pursuit policies…
45y · Female·Multiple injuries
Selina Tilley, a 45-year-old woman, died from multiple injuries sustained during domestic violence perpetrated by her partner Kenneth Mahoney. Over 15 months, Tilley experienced repeated physical assaults, with police in…
2y · Female·Complications of severe anaemia and SARS-CoV2 (COVID-19) infection
A two-year-old girl died from complications of severe iron-deficiency anaemia and COVID-19 infection. She had significant feeding difficulties, took almost exclusively milk and yoghurt, and was profoundly anaemic with po…
86y · Female·Pulmonary thromboembolism in the setting of deep leg vein thrombosis, secondary …
…y apixaban was withheld on day 24 post-op. The coroner found suboptimal VTE prophylaxis administration and missed opportunities for risk re-evaluation, though acknowledged PE can occur despite prophylaxis. Key lesson: cl…
49y · Male·complications of non-small cell carcinoma of the lung
…y not preventable, but the coroner found his final weeks unnecessarily uncomfortable and distressing, with missed opportunities for appropriate symptom management and care planning.
0y · Male·unascertained; possibly asphyxiation related to sleeping position
Noah Harrison, aged 12 weeks, died of unascertained cause in October 2010. He was found face-down in a pram with unsafe sleeping arrangements. At prior hospital admission on 17 September 2010 for fever and reported haema…
44y · Female·haemoperitoneum due to ruptured splenic subcapsular haematoma in the setting of …
Kylie Cay, a 44-year-old woman, was brutally assaulted by her partner Justin Turner on 18 June 2016, sustaining rib fractures and other injuries. She was discharged from hospital on 20 June after imaging did not reveal a…
73y · Male·Complications of cervical fractures and spinal injury (operated), sustained in a…
A 73-year-old man with multiple comorbidities (diabetes, cardiac disease, liver cancer) slipped on wet tiles outside McDonald's and sustained cervical and thoracic spine fractures with spinal cord injury. Attending param…
87y · Female·Natural causes in the context of multiple co-morbidities including a sacral ulce…
87-year-old woman died in aged care with a stage 4 sacral ulcer and multiple comorbidities. Key clinical lessons: (1) Systematic communication failures—family was not informed that a healed sacral wound re-emerged in Mar…
37y · Male·Pulmonary thromboembolus due to left leg deep vein thrombosis
A 37-year-old Aboriginal man died of pulmonary thromboembolism due to deep vein thrombosis while incarcerated. He presented to hospital on his birthday with lethargy, shortness of breath, and tachycardia. Initial assessm…
84y · Male·Gunshot wound to the head
…se, depression, and cognitive decline, died from a self-inflicted gunshot wound to the head. His wife had approached police in 2013 seeking assistance to remove his firearm, expressing safety concerns about his deteriora…
38y · Male·hypoxic brain injury and organ failure following compression of the neck (hangin…
…isk and discharged him without specialist psychiatric review or escalation to on-call psychiatry. Critical missed opportunities included: failure to escalate his case despite three self-harm attempts and asylum seeker st…
5y · Male·Acute bronchopneumonia and diffuse alveolar damage due to acute rheumatic cardit…
…stic momentum, framing, confirmation bias) and failure to use Early Warning scores properly contributed to missed opportunities for escalation. Key clinical lessons include: the value of complete CEWT scoring in detectin…
49y · Male·ligature compression of the neck (hanging)
Barry Matt Stuart, a 49-year-old prisoner at Hakea Prison, died by suicide via ligature compression of the neck in November 2013. Critical clinical lessons include: (1) maintaining psychiatric continuity of care is essen…
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