428 results for “physical assessment”
38y · Male·acute cardiac arrhythmia in a man with cardiomegaly, focal coronary atherosclero…
…e died several hours before discovery, possibly around 7am. Critical clinical lessons include: inadequate physical health monitoring despite documented low oxygen saturations and high-risk cardiac status; a missed opport…
91y · Female·pelvic haematoma arising from a fracture of the neck of the left femur sustained…
…ice to remain in bed. Despite documented dementia with marked short-term memory loss and poor insight, no physical fall prevention strategies were employed (no bed lowering, floor mats, or bed sensors). She fell from her…
15y · Male·Hypoxic-ischaemic encephalopathy complicating cardiac arrest in the setting of b…
…ificate, he collapsed outside a doctor's clinic. Critical learning points: (1) the Vienna GP performed no physical examination before prescribing Lorazepam for travel anxiety, missing signs of serious illness; (2) staff …
28y · Female·acute streptococcus pneumonia meningitis with left-sided otitis media as anteced…
…ere ordered to investigate further. She was inappropriately discharged while clearly unwell and requiring physical assistance. She died at home within 7 hours. Critical system failures included: the supervising senior do…
36y · Male·Hypoxic ischaemic encephalopathy due to cardiac arrest occurring during restrain…
…xwell Heneker, aged 36, died from hypoxic ischaemic encephalopathy due to cardiac arrest occurring during physical restraint by a homeowner. The deceased had entered the homeowner's house without permission while experie…
29y · Male·cardiac arrhythmia triggered by myocardial ischaemia arising from physical exert…
…tegic de-escalation techniques were not employed. While the use of force (OC spray, baton) contributed to physical exertion that triggered his fatal cardiac event, the underlying disease made him extremely vulnerable. Th…
20y · Male·Multiple injuries due to contact with a train
…but identified systemic failures: poor observation practices, inadequate entrance monitoring, and lack of physical controls. Key lessons include the importance of direct patient identification during observations, proper…
80y · Male·asphyxia due to choking on food
…ppropriate. Key lessons: mental health teams did excellent work monitoring him; earlier GP engagement and physical health assessment might have identified the obstructive uropathy and gastrointestinal dysfunction contrib…
72y · Male·The available evidence does not allow for any finding to be made as to the cause…
… approximately five years, experiencing recurrent psychotic episodes. In the months before his death, his physical health declined significantly following severe community-acquired pneumonia with septic shock. On the day…
44y · Male·aspiration pneumonia
…rred from Glenside psychiatric hospital on 11 November 2002 with signs of chest infection and progressive physical deterioration. At RAH, he received appropriate diagnosis and treatment including antibiotics, seizure man…
51y · Male·Hanging
…sk despite standing orders requiring close monitoring of prisoners placed in single cells. Critically, no physical welfare checks were conducted during the 7-hour period following his placement in the cell. The coroner i…
35y · Male·multiple organ failure due to out-of-hospital circulatory arrest due to perforat…
…am despite him being classified as 'high need'; it was called at 4:38am (19 minutes late). No officer was physically present in his cell during the 41-minute period before paramedics arrived. While hospital assessments o…
88y · Female·sepsis of unknown origin
…bly perforated bowel, diverticulitis, colitis, or ischaemic bowel). Clinical lesson: early recognition of physical illness in elderly patients with dementia and behavioural problems is challenging but critical. The patie…
2y · Male·pneumonia in association with bronchiolitis
…foster carer provided appropriate care overall, though with hindsight should have conducted more thorough physical checks during the night when the child was coughing and in the morning before discovery. Children with re…
89y · Female·Blunt force head injury on a background of ischaemic and valvular heart disease
…resident with alcohol-related dementia in an aged care facility. The resident had a documented history of physical aggression, verbal abuse, wandering, and absconding over 19 months. He was transferred from a secure to n…
43y · Female·suffocation
…, aged 43, was killed by her husband through suffocation on 7 March 2017 after years of coercive control, physical violence, and emotional abuse. A critical police response on 17 August 2016 when Ms K reported car vandal…
75y · Male·Burns
…sistent with deliberate ignition. Key clinical lessons: (1) elderly patients with newly diagnosed serious physical illnesses (particularly cancer) carry substantially elevated suicide risk in the immediate post-diagnosis…
44y · Male·Complications of a Left Temporal Lobe Abscess
…ver, and lethargy, no comprehensive medical review occurred. Mental health symptoms masked the underlying physical illness, and systemic failures prevented proper screening and escalation to specialist care. The coroner …
Unknown·Gunshot wound to the head (self-inflicted)
…them vulnerable to impulsive self-harm. Key preventable failures included: inadequate mental health risk assessment at the firing range, lack of physical safety barriers (tethering or ballistic glass), failure to impleme…
46y · Male·Acute hypoxic brain damage resulting from intentional self-inflicted hanging
…ner died from acute hypoxic brain damage following self-inflicted hanging in custody. He had a history of physical health issues including HIV and mental health concerns including anger management difficulties. Despite a…
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