428 results for “physical assessment”
78y · Male·complications of head injuries; antecedent cause: dementia
…arate two incompatible roommates despite identified conflict. The coroner found preventable gaps in risk assessment, clinical communication, incident reporting, and proactive management of behavioral escalation.
0y · Male·Traumatic head injury
BJay Adam Johnstone, 45 days old, died from severe traumatic head injury inflicted by his father Simon Johnstone in a household environment. BJay suffered multiple episodes of violence including head trauma, rib fracture…
19y · Female·combined drug effect and myocarditis
A 19-year-old Aboriginal woman with alcohol and cannabis abuse died at Graylands Hospital from combined drug effect and myocarditis. Following two suicide attempts within 48 hours, she was sedated and transferred via Roy…
33y · Male·Extensive burns sustained when former partner deliberately splashed petrol on hi…
…lation. The children were placed in F's care by interim consent order the previous day after psychiatric assessment diagnosed M with borderline personality disorder and chronic PTSD, identifying her as posing significant…
suicide by hanging or other means
… child protection services or schools. The coroner identified systemic failures in child protection risk assessment (particularly cumulative harm analysis), inadequate mental health services with CAMHS severely under-res…
Unknown·multiple physical injuries sustained in a mid-air collision during skydiving
Three skydivers died in a mid-air collision near Mission Beach, Queensland on 13 October 2017. Tandem instructor Peter Dawson and customer Kerri Pike (in drogue-fall) collided with solo sport jumper Tobias Turner whose m…
25y · Female·Chest injuries due to fall from height
…izophrenic patient who threatened to jump the day of her death but was not assessed or reviewed; no risk assessment was conducted despite clinical deterioration postpartum. AW spent 462 days in an unsuitable acute ward, …
17y · Male·Cardiac arrhythmia during restraint, with previous traumatic brain injury as a s…
…ommunity outings, delayed transition planning, and lack of consistent carers. Key lessons: finalise risk assessments before permitting high-risk activities; ensure comprehensive behavioural guidance is accessible to all …
43y · Male·Hanging
…s admitted to Mildura Base Hospital following a suicide attempt on 11 November 2018. He was placed on an Assessment Order, secluded, physically restrained and sedated with olanzapine after escalating behaviour at lunchti…
35y · Male·self-inflicted gunshot wound to the head
…he death occurred in context of escalating coercive control including verbal abuse, property control, and physical detention. Over seven months, Eileen made multiple police reports and sought help from services; however,…
25y · Female·Airway obstruction complicating laryngeal dilation for the treatment of subglott…
…documentation of staff communications. Although deterioration may have been precipitous, earlier medical assessment following the adrenaline nebuliser administration—which required doctor notification per the prescriptio…
31y · Male·Upper airway obstruction due to pharyngeal abscess caused by dental abscess, whi…
Karl Scholz, 31-year-old male, died from upper airway obstruction due to pharyngeal abscess originating from untreated dental infection. He presented with severe facial cellulitis and abscess following dental procedures …
24y · Male·Coronary artery thrombosis secondary to coronary atherosclerosis
A 24-year-old Aboriginal man collapsed during football in extreme heat and presented to a rural clinic with dizziness, chest pain, shortness of breath and sweating. The nurse diagnosed dehydration and administered IV flu…
72y · Female·Peritonitis due to perforated diverticulum in transverse colon
Maria Donatelli, a 72-year-old woman with cardiac and renal disease, presented to Peel Health Campus with abdominal pain and vomiting. She was initially managed conservatively with a provisional diagnosis of pancreatitis…
21y · Male·Complications of blunt head injury resulting from at least two separate acts of …
…ropriate follow-up. The coroner identified inadequate clinical reasoning regarding non-accidental injury assessment, failure to consult child protection resources, reliance on a potentially inconsistent history, and poor…
33y · Male·Pelvic crush injury sustained while working at an underground coal mine
Jason Blee, a 33-year-old experienced miner and trainer at Moranbah North Mine in Queensland, was fatally crushed on 9 April 2007 when a shuttle car pinned him against a rib (wall) in a narrow underground heading. Follow…
30y · Male·Malignant ventricular arrhythmia without myocardial infarction, precipitated by …
…or weeks. Multiple agencies failed coordinated care, and police tactics prioritized control over welfare assessment despite his known vulnerability.
31y · Male·Complications in association with intestinal volvulus
31-year-old Morgan Edwards with Smith-Magenis Syndrome, cerebral palsy and Crohn's disease was discharged from Fiona Stanley Hospital ED on 14 August 2018 without definitive diagnosis despite elevated respiration rate, u…
36y · Male·perforated duodenal ulcer
…al health worker involvement; and that identification of First Nations status should inform medical risk assessment. The referring physician should have considered perforated viscus.
41y · Male·Cerebral hypoxia and bronchopneumonia; contributing factors: toxic megacolon, ce…
…ude: (1) constipation in people with intellectual disability requires urgent specialist gastroenterology assessment as it can indicate serious pathology including toxic megacolon; (2) pain in non-verbal patients must not…
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