538 results for “observation”
72y · Male·sepsis of undetermined source (pneumonia or spinal epidural abscess)
A 72-year-old man presented to ED with back pain, fever, elevated inflammatory markers (CRP 77.9, high WBC), hypotension (98/59 mmHg at 6:30am), hyponatremia, and hypoalbuminemia—all consistent with sepsis. Despite these…
89y · Male·multi-organ failure with pneumonia due to ingestion of a corrosive liquid (quate…
…en he was actually displaying significant symptoms and the actual quantity was unknown. The PIC advised observation only. Nursing staff failed to escalate to hospital despite the patient later coughing blood. Hospital a…
33y · Male·Fatal cardiac arrhythmia, secondary to acute kidney injury
Joshua Szczudlo, a 33-year-old man with morbid obesity (estimated weight 195kg), underwent shoulder fracture repair surgery on 17 March 2016 at Liverpool Hospital. He died 38 hours post-operatively from a fatal cardiac a…
[47, 77]y · ["male", "female"]·["gunshot injury to head (self-inflicted)", "neck compression"]
Two coronial findings are provided. First, Bayden Roy Smith, 47, died by self-inflicted gunshot wound hours after crisis mental health assessment at Broadmeadows Police Station. The CAT team assessed him as low-risk and …
85y · Male·Heat stroke
An 85-year-old man with dementia, diabetes, and aortic stenosis died from heat stroke after spending 2 hours 18 minutes unmonitored in an unsheltered outdoor garden area at a residential aged care facility. The resident …
34y · Male·hypoxic encephalopathy following hanging
Daniel O'Keeffe, a 34-year-old male with amphetamine abuse and depression, died from hypoxic encephalopathy following hanging in Adelaide Remand Centre on 7 February 2007. He had attempted self-harm twice in custody afte…
32y · Male·Pulmonary embolism originating from deep vein thrombosis in right calf
A 32-year-old man died from pulmonary embolism six days after emergency appendectomy for perforated appendicitis. VTE prophylaxis was appropriately prescribed. However, the clinical team failed to investigate persistent …
20y · Male·Ligature Compression of the Neck (Hanging)
…his brother and father whilst acutely psychotic. Despite appropriate antipsychotic medication and close observation during his 3-day admission, he was not assessed as suicidal and no evidence of suicidal ideation was do…
34y · Male·hypoxic-ischaemic encephalopathy following laparoscopic bariatric surgery with i…
Andrea Lambropoulos, a 34-year-old man with morbid obesity, sleep apnoea, and ischaemic heart disease, died following sleeve gastrectomy. He was admitted to HDU rather than ICU post-operatively. In HDU, he experienced re…
41y · Male·mixed drug toxicity (methadone, valproate, zuclopenthixol)
Michael David Rex, a 41-year-old man with chronic treatment-resistant paranoid schizophrenia, died from mixed drug toxicity (methadone, valproate, zuclopenthixol) while detained in Ward 5H of the Margaret Tobin Centre ps…
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
…ity, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observations were not performed at required frequencies despite policy mandates; (2) a significant drop in Glasgow …
29y · Male·aspiration pneumonia complicating acute and chronic Wernicke's encephalopathy an…
Grant Austin, a 29-year-old man with intellectual disability and morbid obesity, died from aspiration pneumonia complicating Wernicke's encephalopathy. He presented with prolonged refusal to eat and drink from December 2…
35y · Male·neck compression due to hanging
…d. He died by suicide the following morning. Clinical lessons: (1) detained patients require continuous observation—nursing staff alone cannot safely supervise patients determined to leave; (2) security escort arrangeme…
21y · Male·upper airway obstruction and plastic bag asphyxia
Matthew Aaron Condie, a 21-year-old prisoner serving a 12-year sentence at Port Phillip Prison, died by asphyxiation using a plastic bag on 27-28 September 2007. The coroner found his death was potentially preventable du…
4y · Male·Haemophilus influenzae septicaemia with superimposed respiratory tract infection
A 4-year-old previously healthy male presented to Katherine Regional Hospital on 10 September 2023 with fever and eye pain. He was examined, found to have tachycardia (HR 156) and fever (39.2°C), and diagnosed with viral…
30y · Male·cardiac arrhythmia due to therapeutic clozapine use
Edmund James Fern, aged 30, died at a psychiatric institution (James Nash House) on 4 September 1997, nine days after septoplasty for nasal obstruction. He was on multiple medications including clozapine 350mg nightly, c…
5y · Female·myocarditis
A five-year-old girl died from fulminant myocarditis caused by influenza A on 5 July 2022 at Canberra Hospital. The diagnosis was delayed over 7 hours from initial presentation. Critical failures included: ED triage Cate…
54y · Male·Neck compression (hanging)
…on, 54, died by hanging after leaving a private psychiatric hospital on unapproved leave while on close observations. He was admitted with major depression, suicidal ideation, and opioid dependence. On 1 July 2014, desp…
41y · Male·Respiratory depression caused by alcohol and morphine poisoning
Anthony Mark Perry, aged 41, died in police custody at Rockhampton watch house on 23 March 2010 from respiratory depression due to morphine and alcohol. He was arrested for breaching a domestic violence order after drink…
36y · Male·hanging
Troy Phillip Turner, aged 36, died by hanging in his prison cell on 2 September 2001 while on remand for serious domestic violence-related offences. The coroner identified several preventable failures: (1) Duty Superviso…
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