538 results for “observation”
93y · Male·Intracranial haemorrhage in the setting of over-warfarinisation
A 93-year-old man on warfarin for atrial fibrillation sustained a head strike in a fall at residential aged care. Initial assessment by ambulance was appropriate and he was not transferred. Over subsequent days, neurolog…
2y · Male·morphine toxicity
…'s medication left unguarded in the home. Hospital care was appropriate, with nurses performing regular observations and showing good clinical vigilance. However, there was a critical transition point: detailed neurolog…
18y · Female·Severe cardiogenic shock caused by myocarditis as a consequence of an unknown vi…
Ivy Dwyer, 18, died from viral myocarditis causing cardiogenic shock. She presented over weeks with progressive non-specific symptoms (nausea, vomiting, fatigue, cough) consistent with viral illness. A locum GP diagnosed…
24y · Male·acute hydrocephalus due to undiagnosed colloid cyst of the third ventricle of th…
Brendan Burns, 24, died from acute hydrocephalus caused by an undiagnosed colloid cyst of the third ventricle. He presented with progressive severe occipital headaches, dizziness, blurred vision, nausea and vomiting over…
50y · Male·Multiple pulmonary thromboemboli due to deep vein thrombosis following pharyngea…
A 50-year-old man died from pulmonary thromboembolism following uvulopalatopharyngoplasty (UPPP) surgery for obstructive sleep apnoea. Critical failures in post-operative management at a private hospital included: failur…
52y · Male·Unascertained
GM, a 52-year-old man with bipolar affective disorder, died of unascertained causes after absconding from a mental health inpatient unit on 2 December 2015. He was admitted voluntarily for management of a suspected manic…
30y · Male·Complications of methylamphetamine toxicity
Matthew Dongelmans, aged 30, died from complications of methylamphetamine toxicity after being arrested for breaching a family violence intervention order. He consumed methylamphetamine prior to arrest, likely in panic w…
41y · Female·salt water drowning
…h Australia. She aspirated water triggering laryngospasm and became unresponsive within minutes of last observation. Critical clinical lessons include: inadequate pre-tour risk assessment of swimming ability; insufficie…
74y · Male·small intestinal ischaemia caused by aortic atherosclerosis
A 74-year-old man presented to hospital with abdominal pain following a fall. He developed hypotension, fever, tachycardia, and elevated inflammatory markers consistent with sepsis within hours of admission. Despite clea…
45y · Male·subdural haemorrhage sustained in a fall
…ing, other clients woke and left between 6-7am, but Mr Ware remained asleep. Despite normal half-hourly observations, staff did not wake him to assess his wellbeing, assuming he was simply sleeping off intoxication. At …
32y · Female·Sepsis due to pyelonephritis of the right kidney due to acute and chronic cystit…
A 32-year-old Vietnamese-speaking woman died from sepsis due to pyelonephritis following premature discharge from hospital onto a midwifery support program. Multiple missed diagnostic opportunities occurred: difficulty p…
43y · Male·Hanging
William Epere, aged 43, died by hanging in custody at Dawn de Loas Correctional Centre on 10 January 2019. He had been remanded in custody for 27 days following repeated breaches of a domestic violence order, despite cle…
25y · Male·Hypoxic ischaemic brain injury due to hanging
Dylan Charlton-Smith, aged 25, died by hanging while in custody at Fulham Correctional Facility. A stressful visit from his partner preceded his death by approximately 50 minutes. A correctional officer identified distre…
60y · Male·Multiple injuries sustained after jumping from 15th storey home unit
William MacKenzie, a 60-year-old with a five-year history of bipolar affective disorder and recent involuntary hospitalization, presented to St. Vincent's Hospital on 9 June 2008 with suicidal ideation after being found …
52y · Female·Mixed drug toxicity (methadone, pregabalin, valproic acid, benzodiazepines)
A 52-year-old woman with chronic pain, epilepsy, and opioid dependence died from mixed drug toxicity after prescribed methadone, pregabalin, valproic acid, and benzodiazepines. She was admitted to Box Hill Hospital on 12…
34y · Male·Staphylococcus aureus sepsis and endocarditis
…cterial infection. Despite these findings, he was diagnosed with viral gastroenteritis and admitted for observation. Dr B. discharged him at 7.35pm after one examination, without discussing with senior colleagues or com…
62y · Male·cardiac arrhythmia secondary to prolongation of the QT interval
…, and they were not discussed at a multidisciplinary team meeting despite prior plans to do so. Nursing observations on the night of death were inadequate—chest movement was likely mimicked by breeze through an open win…
76y · Female·multi-organ failure and sepsis due to complications of cholecystectomy
A 76-year-old woman died from multi-organ failure and sepsis following a laparoscopic cholecystectomy at a rural hospital. During surgery, the surgeon became misoriented in the inflamed surgical field and divided the com…
72y · Male·Bilateral pneumothoraces and pneumoperitoneum due to insufflation of the bladder…
Stephen Herczeg, a 72-year-old patient with COPD and urinary tract infection, died from bilateral pneumothoraces and pneumoperitoneum caused by insufflation of his bladder with oxygen. The oxygen supply tubing was someho…
45y · Female·Extensive retroperitoneal haemorrhage following bone marrow biopsy procedure wit…
…ssed imaging-guided biopsy, expedited notification of abnormal blood results, and complete recording of observations.
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