171 results for “ultrasound”
0y · Female·Intrapartum hypoxia due to breech delivery with head entrapment and associated c…
… of vaginal breech delivery, the urgency of hospital attendance once labour started, and the accuracy of ultrasound imaging. While Dr S.'s advice and clinical management were deemed adequate, the family's failure to reco…
Philip Byrne: pulmonary thromboembolism due to right calf deep vein thrombosis; …
…th right calf pain in February 2012; two GPs excluded DVT on clinical examination alone without ordering ultrasound despite his history of previous DVT. Mrs Weaver presented with left calf pain, chest pain and palpitatio…
66y · Male·carcinomatosis complicated by recurrent sepsis and multisystem failure in a man …
…pite recurrence and negative infection workup. A prison doctor (Dr H.) initially recognised the need for ultrasound but failed to arrange it, becoming distracted by concurrent findings of diabetic nephropathy. The tumour…
77y · Male·Complications of metastatic squamous cell carcinoma, likely urothelial origin
Jack King, aged 77, died of metastatic squamous cell carcinoma (likely urothelial origin) while in custody at Long Bay Correctional Centre Hospital's Aged Care Rehabilitation Unit on 20 September 2020. He had been diagno…
56y · Male·Liver cancer (hepatocellular carcinoma)
Phillip John Wust, a 56-year-old prisoner with chronic hepatitis C and cirrhosis, died from hepatocellular carcinoma. Serial imaging from 2018-2019 showed cirrhosis but no evidence of cancer until December 2019 when he p…
83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)
…idental finding of an 8.7 cm AAA was identified on a lumbar spine X-ray in August 2021, but confirmatory ultrasound and CT imaging were not performed until February 2022. Critical failures included: the PMO's failure to …
25y · Female·ruptured splenic artery aneurysm with haemorrhage and internal blood loss
…gardless of initial stability; (2) consultant involvement was absent until final collapse; (3) a planned ultrasound examination was not carried out despite clinical deterioration; (4) the 'double rupture phenomenon' with…
60y · Male·haemopericardium due to rupture of right ventricle complicating removal of cardi…
…y while an unproductive pulmonary angiogram was performed instead. The coroner found that had diagnostic ultrasound been immediately available, the haemopericardium diagnosis would have been made promptly, allowing earli…
84y · Male·haemoperitoneum due to ruptured abdominal aortic aneurysm
Bernard Greenwell, an 84-year-old male, died from rupture of an abdominal aortic aneurysm (AAA) while in custody at Cessnock Correctional Centre. He experienced sudden-onset severe left groin pain at 11:30am on 25 April …
55y · Male·gastrointestinal haemorrhage due to oesophageal varices due to hepatocellular ca…
…. Key clinical lessons include: earlier specialist surveillance for known hepatitis C and cirrhosis with ultrasound screening for hepatocellular carcinoma; better detection of subtle liver dysfunction markers; adoption o…
71y · Female·Ruptured abdominal aortic aneurysm, with coronary artery atherosclerosis contrib…
… becoming dismissive of the local doctor; (3) the retrieving doctor (Dr J.) performed an inadequate FAST ultrasound, over-relied on a negative result, and incorrectly prioritized sepsis as the working diagnosis; (4) crit…
51y · Male·Sepsis due to or as a consequence of right lower limb necrotising fasciitis due …
…e and act on post-procedure bleeding complications—a competent cardiologist should have performed urgent ultrasound imaging on 11 May to exclude pseudo-aneurysm, which could have been treated with thrombin injection; (3)…
59y · Male·Disseminated carcinoma on a background of emphysema
Robert Fullerton, a 59-year-old Aboriginal man from Palm Island, died from disseminated carcinoma while remanded in custody at Townsville Correctional Centre. He presented with abdominal pain on 5 December 2018, was diag…
85y · Male·metastatic prostate cancer
An 85-year-old man died of metastatic prostate cancer while in custody serving a sentence for historical child sexual offences. He had declined investigation and treatment for prostate cancer when an enlarged prostate wa…
71y · Female·multiple pulmonary thromboemboli and deep vein thrombosis
…e leg pain/swelling over one week. ECG showed S1Q3T3 pattern consistent with pulmonary embolism; bedside ultrasound showed right ventricular strain. Despite presumptive diagnosis of PE being made, no anticoagulation or t…
0y · Male·subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour
…al position must be definitively established before instrumental delivery using clinical examination and ultrasound if uncertain; unaccredited registrars require direct supervisor presence; slow labour progression should…
62y · Male·metastatic hepatocellular carcinoma
…ossible cirrhosis. The critical clinical lesson is that Mr Curran should have received six-monthly liver ultrasound screening—the international gold standard for cirrhotic patients—but this never occurred. The cancer was…
42y · Male·disseminated metastatic renal cell carcinoma
…year-old prisoner died from disseminated metastatic renal cell carcinoma. Renal cancer was identified by ultrasound in September 2006 and confirmed by CT scan. Surgery was performed with curative intent in December 2006,…
43y · Male·Hypoxic brain injury secondary to haemopericardium and tamponade complicating ru…
…ration of the right ventricular outflow tract (RVOT), possibly from the drainage needle inserted without ultrasound guidance. Despite resuscitation and emergency transfer to a tertiary cardiac centre, he suffered irrever…
2y · Male·cardiorespiratory arrest in a young child with opioid (morphine) toxicity
…fect at 50-90 minutes), failure to observe fasting protocols prior to sedation, and failure to review an ultrasound showing undescended testicles which might have changed management decisions. Expert evidence confirmed t…
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