538 results for “observation”
2y · Male·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest secondary to up…
…ven nebulised adrenaline by ambulance and dexamethasone at hospital, then discharged after only 3 hours observation despite ongoing stridor. Queensland Health guidelines required 4+ hours observation post-adrenaline bef…
49y · Male·cor pulmonale and chronic bronchitis and emphysema
…ssons include ensuring rapid escalation of medical concerns in custodial settings and maintaining close observation of high-risk prisoners. The coroner commended the introduction of a medical emergency code and an obser…
80y · Male·Drowning
…psychiatric ward. He was appropriately treated with ECT, medication, and placed on an ITO. However, his observation schedule was erroneously changed from 15-minute to 30-minute intervals by nursing staff without medical…
26y · Female·compression of the neck consequent upon hanging
…ed suicidal ideation and threats during admission, she was assessed as 'low risk' and placed on general observation rather than high dependency care. She absconded on 22 June but returned cooperatively. On 24 June, appr…
58y · Male·hanging
…om all contacts; improving communication between informal sources and authorities; and mandating direct observation of prisoner wellbeing during checks rather than observation of body shape alone.
31y · Male·undetermined
…y rates (48-49 breaths/min) at 10:05pm and 10:29pm on 29 November were not escalated using standardised observation charts; (2) risk of staff violence prevented full physical examination; (3) escalation should have occu…
37y · Female·Hypoxic brain injury consequent upon hanging
…cide two weeks prior (overdose). Despite being assessed as high-risk on 4 December and placed on hourly observations, she hanged herself using the nurse call button cable shortly after midnight on 5 December. Clinical l…
18y · Female·neck compression due to hanging
…s, inappropriate downgrading of her suicide risk status despite clear high-risk indicators, ineffective observations during critical periods, and an earlier inappropriate ward transfer that disrupted therapeutic continu…
31y · Male·Hanging
…onal Centre on 22 January 2013. He had been assessed as high-risk for self-harm and placed on 30-minute observations, but these observations were not conducted as required. Critical failures included: observations staff…
33y · Male·complications of acute peritonitis caused by rupture of a duodenal ulcer
…ical gaps included: (1) Justice Health's Health Problem Notification Form (HPNF) instructions regarding observation and monitoring signs were never read by custodial officers; (2) no effective observation of Mr Tran-Bui…
58y · Female·plastic bag asphyxia
… plastic bag and shower cap, which were not adequately controlled as high-risk items. Overnight nursing observations failed to detect her death for several hours. The coroner found that adherence to proper observation p…
27y · Male·Global cerebral ischaemic injury in the setting of hanging
…anged himself using a bed sheet attached to a toilet door frame within approximately 30 minutes of last observation. Clinical experts disagreed about risk stratification and observation frequency. The coroner found psyc…
29y · Male·hanging
… was admitted to a psychiatric inpatient unit on involuntary status. Despite being prescribed 15-minute observations by his treating psychiatrist, nursing staff implemented an undisclosed informal practice of hourly obs…
65y · Male·Hanging
…e psychiatric ward, died by suicide via hanging. He had been assessed as high-risk and was on 15-minute observations as ordered by his psychiatrist. Two systemic failures contributed to his death: (1) routine overnight …
55y · Male·Complications of alcohol use disorder
…lications of alcohol use disorder. Critical failures in clinical care included: inadequate recording of observation frequency by the medical officer; failure to document vital signs appropriately; insufficient monitorin…
20y · Male·Multiple injuries due to contact with a train
…ly absconded the same day but returned voluntarily. He was placed in a low-dependency unit on 30-minute observations rather than a locked intensive care unit, based on therapeutic reasoning to maintain trust and avoid r…
23y · Female·hypoxic ischemic encephalopathy and aspiration pneumonia as a result of hanging
…rest or hospitalization, which was inappropriate given her Aboriginal status and family importance; and observation practices were not contemporaneous or rigorous. While observation level was increased to 15-minute inte…
Bearham: hypoxic brain injury from hanging; Fisher: asphyxiation from hanging by…
…one by jumping. The coroner found systemic failures including inadequate ligature risk mitigation, poor observation procedures, failure to properly search for dangerous items, inadequate staff training, and communicatio…
21y · Male·unascertained
…fied several system gaps impacting safety: difficulty visualizing patient respirations during seclusion observation, unclear allocation of nursing responsibility, inconsistent CPR assessment protocols, and incomplete re…
1y · Female·aspiration of gastric contents due to recent gastroenteritis and vomiting leadin…
…ation showed moderate dehydration with tachycardia, yet she was discharged the same evening after brief observation. The coroner found that standard hourly observations were not performed, blood tests were not obtained,…
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