538 results for “observation”
25y · Male·cerebral craniopharyngioma
…commenced symptomatic treatment. He was admitted overnight under Dr T. (RMO) with 2-hourly neurological observations. The deceased's headache was fluctuating (8/10 to 3/10 to 6-7/10) but he remained alert and orientated…
48y · Female·Mixed drug toxicity (morphine, codeine, venlafaxine, amitriptyline and zopiclone…
A 48-year-old woman with depression, anxiety, and bipolar disorder died from mixed drug toxicity while on voluntary inpatient psychiatric admission. She had undisclosed significant illicit drug use, which was not identif…
57y · Female·Intra-abdominal Haemorrhage following Appendectomy, with contributing factor of …
A 57-year-old woman with COAD, hypertension, and unrecognized severe coronary atherosclerosis presented with appendicitis. Surgery was performed by an unsupervised surgeon operating on friable tissues with limited visibi…
43y · Female·choking on a food bolus
…ther shift, another escorted clients elsewhere, and seating arrangements prevented direct line-of-sight observation of Joanne. Staff responded appropriately once choking was recognized, but earlier detection might have …
53y · Male·decompensated alcoholic liver disease in the setting of gastro-intestinal haemor…
…monitoring, and failure to escalate for medical assistance were evident. Key lessons: maintain physical observation protocols rigorously for intoxicated detainees, recognise language barriers in clinical assessment, esc…
12y · Female·Cardio-respiratory failure due to aspiration pneumonia
Angelique Burton-Ho, age 12, with VACTERL syndrome and difficult airway, presented to Bowral Hospital ED on 9 August 2015 with respiratory symptoms. She was inadequately triaged initially, then readmitted that evening wi…
60y · Male·Hypertensive heart disease with chronic fatty liver as other significant conditi…
David Duggan, a 60-year-old man with hypertensive heart disease and cardiomegaly, was admitted to Caloundra Hospital on 10 January 2007 for management of severe acute back pain caused by a suspected L3/4 disc herniation …
89y · Female·acute-on-chronic renal failure on a background of ischaemic heart disease, hyper…
An 89-year-old Aboriginal woman with chronic renal impairment and congestive cardiac failure was prescribed gentamicin intramuscularly for a urinary tract infection caused by Klebsiella aerogenes. Gentamicin is nephrotox…
0y · Male·Complications in association with fulminant sepsis in an infant (Streptococcus p…
Malakai Paraone, a seven-month-old infant, died from fulminant Streptococcus pyogenes sepsis and septic shock. Over three days, he was seen at three hospitals and a general practice clinic but sepsis was not identified. …
58y · Male·acute bronchopneumonia
Giovanni Trotta, aged 58, died in custody from acute bronchopneumonia. He was a vulnerable prisoner with COPD, schizoaffective disorder, and profound deafness. Clinical lessons include: (1) hospital discharge summaries m…
45y · Female·Multi-organ failure due to septicaemia and peritonitis due to faecal leakage fro…
…mplications identified early (days 1-3 post-op) should trigger prompt revision rather than conservative observation, particularly when there are objective signs of compromise. Discharge decisions require senior surgical…
Male·Neck injury in a man with atherosclerotic heart disease
Ashley James Bropho, a vulnerable remand prisoner with intellectual impairment, schizophrenia, diabetes, previous myocardial infarction with stent, and atherosclerotic heart disease, was killed on 9 March 2023 at Hakea P…
19y · Male·Hanging
Meqdad Hussain, a 19-year-old Afghan asylum seeker, died by hanging in an immigration detention centre (Scherger IDC, Queensland) on 17 March 2011. He had a history of self-harm evident from scars on his forearms, noted …
32y · Female·massive postpartum intracerebral haemorrhage of spontaneous hypertensive origin
A 32-year-old woman with Factor V Leiden mutation died from a massive postpartum intracerebral haemorrhage of hypertensive origin five hours after delivering twins. She had been diagnosed with pregnancy-induced hypertens…
40y · Female·The medical cause of death was unable to be determined. Manner of death: uninten…
…id not consult the on-call psychiatrist despite clear psychotic symptoms and paranoia; (3) insufficient observation and management on the unit – she was permitted unescorted leave while highly agitated despite no recent…
18y · Male·Ligature Compression of Neck (Hanging)
Adam Timothy Garner, aged 18½, died by hanging in his prison cell at Canning Vale Prison Complex on 6 January 2000, approximately 24 hours after admission. He was on remand for a serious violent offence and was experienc…
71y · Male·sepsis caused by mediastinal empyema (abscess) which complicated perforation of …
…cognised procedural risk and the surgeon was experienced, earlier diagnosis and overnight admission for observation would have enabled timely intervention.
1y · Female·Rapidly developing Streptococcus pneumoniae infection leading to invasive pneumo…
…d lay face-down unmonitored while deteriorating; (4) Safe sleeping policies must mandate active, direct observation assessing breathing and skin colour, not passive CCTV monitoring alone; (5) Childcare providers must en…
37y · Male·self-inflicted gunshot wound to the head and neck
Matthew Lothian, aged 37, died from a self-inflicted gunshot wound to the head and neck on 6 January 2021 in Wollongong. He was on medical escort from custody when he seized the firearm from Correctional Services Officer…
1y · Female·Obstructive sleep apnoea occurring in the context of significant, unrecognised h…
…ad-sparing growth pattern, and meeting clear policy criteria requiring glucose monitoring and inpatient observation. The discharging paediatrician, Dr H.-Gamage, failed to identify these risk factors, misunderstanding h…
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