25 results for “possible acute systemic illness”
39y · Male·multiple injuries from motor vehicle collision
…error did not directly cause the death (the deceased was not driving a truck when he died), it highlights systemic failures: inadequate communication between GP and psychiatrist about the fitness-to-drive assessment, unc…
32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …
…titioners, community mental health service, and the hospital meant the hospital was unaware of her mental illness. After delivery, she stopped taking clozapine due to inadequate medication management by maternity staff.…
Male·Transection of the aorta with exsanguination caused by gunshot wounds to the mid…
…ed to his father he would 'be shot by police' but this information was not conveyed to responders. Better systemic coordination, information systems, training on mental health crises, and community support could have pot…
60y · Male·asphyxia sequential to hanging due to depression
…d family involvement in the discharge plan was inadequate. The coroner found no negligence but identified systemic failures in information sharing, clinical governance, and documentation that contributed to this preventa…
asphyxia sequential to hanging (all three cases); Charles Barlow: schizophrenia …
…ff, and failure to escalate to specialist psychiatric services. All three had documented suicide risk but systemic failures prevented appropriate intervention.
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