185 results for “triage assessment”
1y · Female·viral respiratory tract infection (Parainfluenza and Respiratory Syncytial Virus…
…to ED twice in two days with febrile illness, poor intake, and lethargy. At first presentation, clinical assessment was appropriate and she improved with supportive care, then was discharged home. At second presentation …
78y · Male·Complications of bowel surgery; specifically post-operative chest infection and …
… predisposing to infection. Critical clinical lessons: (1) his initial ED presentation on 7 August was not triaged or recorded despite describing concerning symptoms; (2) communication between referring doctor and imagin…
72y · Female·Pneumonia in the setting of multiple rib fractures and chronic obstructive pulmo…
… Friday with severe (9/10) right-sided chest pain from multiple rib fractures sustained in a fall. She was triaged to Category 5 (least urgent) despite severe pain and high-risk comorbidities. Although examined quickly, …
16y · Male·Bacterial meningitis
…to consider meningitis despite overlapping symptoms with gastroenteritis. The nurse did not perform formal triage. The coroner found the symptoms were suggestive of meningitis such that it could not be ruled out. Systemi…
4y · Male·Peritoneal sepsis caused by a perforated duodenal ulcer
…quately reconsidered despite accumulating abnormal pathology; (4) the daytime team did not perform fresh assessment of the clinical picture but were influenced by preceding teams' reassurance; (5) tele-triage nurses lack…
29y · Female·Multiple injuries due to fall from height
A 29-year-old woman with rapidly deteriorating mental health presented to Ipswich Hospital ED triaged as ATS Category 3 requiring assessment within 30 minutes. Multiple systemic and clinical failures delayed…
7y · Female·multiorgan failure due to fulminant sepsis (Streptococcus pyogenes)
…ncy department. She presented with gastrointestinal symptoms, fever, cold extremities and lethargy but was triaged as low-acuity (category 4). Critical missed opportunities occurred: a junior doctor performed only a focu…
23y · Male·Multiple injuries sustained following collision with a train
…ory of schizophreniform disorder, depression, and previous suicide attempts absconded from a mental health triage facility after being involuntarily admitted. He had previously absconded in 2016, reported planning to sta…
39y · Male·Effects of fire (self-immolation)
…ning, and hallucinations. His GP's referral letter documented significant safety concerns. However, he was triaged as Category 4 despite appearing well and driving himself. Mental Health Triage assessment was delayed due…
51y · Male·Combined drug toxicity (methadone and benzodiazepines) in a man with coronary an…
… not appropriately escalated. The CHAL nurse failed to direct police to ascertain proper conscious state assessment or call an ambulance despite clear red flags. Police also did not apply the medical checklist before cal…
30y · Male·unascertained
…h self-inflicted lacerations. His brother Adam contacted the Mental Health Service twice seeking help. The triage service failed to mobilise a home assessment team, instead requesting the patient attend a clinic—unrealis…
42y · Male·ischaemic heart disease due to coronary atherosclerosis
… morning of 19 May) with prior stent history. Critical communication and history-taking failures occurred: triage notes were inaccurate, nurse Wu misinterpreted timing of pain episodes, and Dr N. failed to obtain complet…
Female·Sudden Unexpected Death in Infancy (SUDI), otherwise undetermined
…onments were repeatedly closed without intervention. The coroner found FACS should have conducted urgent assessments and safety planning in the months before the first child's death.
23y · Female·Hypoxic-ischaemic brain damage due to self-inflicted hanging with intention of t…
…fter her release from custody on bail. The inquest identified multiple systemic failures in supervision, assessment, and coordination between services rather than individual clinical failures. Key issues included: inadeq…
18y · Male·compression of the neck in keeping with hanging
…pon release, there was a critical communication breakdown: the mental health service received a non-urgent triage despite reports of possession delusions, hallucinations, and new threats to harm others. The referral was …
42y · Female·Traumatic right subdural haematoma
… found unresponsive at home with severe head and facial injuries after falls. Critical delays in medical assessment occurred when her partner called a home doctor service at 5.14pm reporting a major head injury with swol…
37y · Male·hypoxic encephalopathy due to asphyxia from hanging
…l Emergency Department at 5:02am on 10 July 2016 in mental health crisis with suicidal ideation, correctly triaged as Category 3 (urgent, requiring assessment within 30 minutes). However, he waited 42 minutes in the publ…
24y · Male·Aspiration pneumonia secondary to drug abuse and overdose of multiple drugs
…auditory hallucinations and presented to his mother's home sedated. His mother contacted the mental health triage service; the practitioner advised half-hourly observations at home rather than hospital admission. The mot…
0y · Female·Myocardial infarction
…dics should record all observations and clinical findings in patient care reports, not just interventions; triage systems must account for neonatal presentations which differ from adults; early senior neonatal input is e…
26y · Female·meningococcal infection (Neisseria meningitidis W strain) causing septicaemia
… and vomiting. Clinical lessons include: (1) ED overcrowding resulted in a one-hour delay before medical assessment; (2) her Triage Code 3 may have been inappropriately conservative given severe pain warranting Code 2; (…
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