59 results for “oxygen administration”
51y · Male·ischaemic heart disease
A 51-year-old prisoner died from ischaemic heart disease after suffering a cardiac event while being transferred between prison units. He had complained of chest pain to correctional officers, was directed to walk to the…
3y · Male·respiratory failure, with spinal muscular atrophy an antecedent cause
…despite his life-limiting diagnosis, limitation of respiratory support options during transfer (humidified oxygen unavailable in NETS ambulance), severe malnutrition contributing to respiratory compromise, and inadequate…
60y · Male·Neck injury, specifically fracture of the odontoid peg of the second cervical ve…
Gary Witcombe, a 60-year-old man, died from a fractured odontoid peg of the second cervical vertebra with associated spinal cord damage sustained during a physical altercation at a family birthday party. The injury cause…
77y · Male·aspiration pneumonia due to dysphagia on a background of dementia
…deteriorated with persistent chest congestion despite supportive care including suctioning, nebulisers and oxygen. He was found unresponsive on 31 October 2014 and died shortly after. The clinical course followed an appr…
54y · Female·Opioid toxicity (predominantly fentanyl)
… not communicated to Dr Y.. The patient vomited medications on the evening of 9 July and developed reduced oxygen saturation (94%), but was re-dosed with methadone without escalation to the anaesthetist. She was found un…
64y · Female·fatal cardiac arrhythmia in a lady with obstructed sleep apnoea, obesity and suf…
…Initially admitted to ED where she was sedated with haloperidol and clonazepam. Despite recording hypoxia (oxygen saturation 93%) and requiring supplemental oxygen overnight, she was transferred to an aged-care psychiatr…
50y · Male·coronary atherosclerosis
A 50-year-old Tamil Sri Lankan man in immigration detention at Curtin IDC died from severe coronary atherosclerosis. He was assessed using a temporary "fast track" health screening process due to overcrowding at Christma…
76y · Female·Aspiration pneumonia and cholangitis; obstructive jaundice from intraduct tumour…
… obstruction and stent insertion. Despite antibiotic therapy and supportive care including transfusion and oxygen therapy, she developed progressive aspiration pneumonia and fluid overload, deteriorating to death on a pa…
57y · Male·Multiple Organ Failure and Intra-Abdominal Haemorrhage following Cholecystectomy
…l for complex post-operative recovery; the deceased was not intubated despite respiratory failure and high oxygen requirements.
44y · Male·aspiration pneumonia
Christopher Hollens, a 44-year-old man with chronic schizophrenia, traumatic brain injury, spastic paraparesis, and epilepsy, died of aspiration pneumonia after a 15-day admission to Royal Adelaide Hospital. He was trans…
69y · Male·metastatic squamous cell carcinoma of the lung with chronic obstructive lung dis…
Barry John Matthews, aged 69, died of metastatic squamous cell carcinoma of the lung with chronic obstructive lung disease at an aged care facility while subject to a section 32 detention order. He had undergone chemothe…
55y · Male·Cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and…
…res included: inadequate recognition of respiratory depression risk despite known COPD, lack of continuous oxygen saturation monitoring with pulse oximeter, insufficient respiratory rate monitoring, failure to exclude de…
20y · Male·hypoxic encephalopathy
…ube was correctly positioned. Despite clinical evidence of malposition—bile emerging from the ETT, falling oxygen saturations despite 100% oxygen, and later abdominal distension—the incorrect assessment was accepted by a…
42y · Female·Global cerebral ischaemia in a setting of anaesthesia
A 42-year-old woman died from global cerebral ischaemia following cardiac arrest during anaesthesia for a late-term termination of pregnancy. The anaesthetist, Dr McAllister, failed to obtain or ensure a functioning puls…
79y · Male·Urinary tract infection with E coli bacteraemia on a background of ischaemic hyp…
…a Hospital ED following a fall. Paramedics documented concerning vital signs (tachypnoea, tachycardia, low oxygen saturation, fever) and a history suggestive of sepsis (6-day UTI symptoms, rigors, confusion). The ED RMO …
59y · Male·complications of viral liver cirrhosis with hepatocellular carcinoma
Mervyn Morgan, aged 59, died from complications of hepatocellular carcinoma arising from cirrhosis while in prison custody. Critical failures included: delayed monitoring of known liver cirrhosis (no ultrasound despite M…
2y · Male·Cardiorespiratory arrest in a young child with opioid (morphine) toxicity
…ncluded: no fasting instructions despite using an opioid that causes vomiting; no continuous monitoring of oxygen levels or vital signs; and discharge from the clinic while still deeply asleep, less than 1.5 hours after …
34y · Male·ischaemic heart disease secondary to coronary atherosclerosis as an antecedent c…
… Suboxone (guidelines suggest 7 days minimum), given his morbid obesity, undiagnosed sleep apnoea, and low oxygen saturation (94%). The coroner found systemic resourcing failures at Junee Correctional Centre, not causati…
80y · Female·Acute upper airway obstruction secondary to aspiration of food bolus
Beatrice Ivy Brown, aged 80, died at an aged care facility from acute upper airway obstruction and aspiration of a food bolus following a choking episode. Clinical lessons include: (1) documentation of prior choking epis…
43y · Male·Septic shock from streptococcus pneumoniae sepsis arising from streptococcus pne…
…e septic shock. He presented to a rural hospital ED on 6 November 2007 with respiratory compromise and low oxygen saturation (83%). Dr Y. assessed him from across the room without examination, dismissing him as Category …
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