538 results for “observation”
17y · Female·Acute Methylenedioxymethylamphetamine (MDMA) toxicity
…ed despite this being a guideline requirement. She was discharged after 25 minutes with only one set of observations taken, when multiple observations were recommended. No paramedics, nurses, or doctors were available o…
75y · Female·pyelonephritis and pneumonia
Molly Jessie Smith, a 75-year-old woman with longstanding severe mental illness, died of pyelonephritis and pneumonia on 16 August 2009. She had been in state psychiatric care continuously for 53 years. During her final …
26y · Female·sepsis
…s until late, absence of IV fluids despite ordering them, poor handover to night staff, inadequate ward observations, and lack of recognition of sepsis severity. The coroner found her death was potentially avoidable wit…
6y · Male·Sepsis due to melioidosis
A six-year-old previously healthy boy died from sepsis due to melioidosis after multiple presentations to a remote hospital over five days (5–10 January 2017) with fever, vomiting, diarrhoea, and headache. Initial diagno…
69y · Female·multi-organ failure due to sepsis of unknown origin
A 69-year-old woman with diabetes, cardiac disease, and vulnerable kidneys died from multi-organ failure due to sepsis of unknown origin. She presented to a rural hospital on 28 June 2012 with vomiting, dehydration, and …
24y · Male·cardio-respiratory arrest due to multi-drug toxicity
…e sedation despite therapeutic dosing; ensuring robust communication systems for clinically significant observations (patient drug-seeking behaviour); strict medication administration oversight; and maintaining advanced…
39y · Male·head injuries sustained in boat collision with rock seawall
Timothy Gerard O'Neill died from head injuries sustained in a boat collision with an unlit rock seawall at the mouth of the Brisbane River on 13 September 2007. The vessel, skippered by Andrew Coronis with limited night …
2y · Male·Tramadol toxicity in the setting of adenotonsillectomy in a child with Pierre Ro…
Dane Hortle, a 2-year-old with Pierre Robin Sequence and obstructive sleep apnoea, died from tramadol toxicity following adenotonsillectomy. He was discharged with a prescription for tramadol 25mg, which was dispensed as…
67y · Male·Head injuries sustained from a fall from the upstairs landing in Goldsmith G Blo…
…ppropriate psychiatric care and was cleared from the Mental Health Screening Unit after three months of observation. However, critical failures occurred: (1) his emergency contact details were not recorded in the prison…
41y · Male·Subdural haematoma
A 41-year-old Aboriginal man with excessive alcohol use presented four times to a rural hospital over one month with headaches. His symptoms were attributed to cluster migraine, then alcohol withdrawal syndrome, despite …
Female·Vlasta Wylucki: ischaemic heart disease due to coronary atherosclerosis (previou…
Two women died of natural causes in Queensland police watchhouses but supervisory failures raised serious concerns. Ms Wylucki (50) died from ischaemic heart disease after inadequate cell checks failed to detect her vomi…
50y · Male·gastrointestinal haemorrhage; haemorrhage from cystic artery post laparoscopic c…
A 50-year-old man died from gastrointestinal haemorrhage involving both a cystic artery and duodenal defect following laparoscopic cholecystectomy. Over five days post-surgery, he developed repeated episodes of hypotensi…
41y · Male·Head Injury in a Man with Acute Alcohol Intoxication; basal skull fracture with …
…ty for diagnosis. The patient was released to friends despite meeting standard criteria for head injury observation. Subsequent signs of deterioration at a BBQ were misattributed to intoxication by his friends. He died …
18y · Female·Mixed drug toxicity
Tiesha Marie Derbyshire, an 18-year-old with complex mental health conditions including eating disorder, PTSD, and borderline personality disorder, died from mixed drug toxicity after intentionally overdosing on proprano…
49y · Male·Unascertained - cardiac arrhythmia with terminal aspiration in an overweight man…
…challenging. The case highlights systemic issues in mental health handovers and the need for continuous observation technology.
41y · Female·ligature compression of the neck (hanging)
…y meetings; poor handover processes when the consultant psychiatrist took leave; superficial 'rounding' observations; and premature risk downgrade from high to low without documented justification. Ward 6 was under-reso…
61y · Male·Undetermined
…lines were not followed; vital sign monitoring ceased at 7:45am on 4 April despite guidelines requiring observations for 72 hours; no ECG was performed on 4 April despite orders and guidelines requiring ECGs at 24 hours…
30y · Male·Hanging
Joshua Stachor, aged 30, died by hanging in Yatala Labour Prison on 19 November 2017. He was a remand prisoner on charges of domestic violence. The coroner found critical failures in his admission assessment on 6 Novembe…
26y · Male·severe closed head injury associated with severe fractures of the cranial vault …
…on. Had Prison Health Service known the full risk profile, Gill would have been placed in high-security observation or infirmary, not the general population unit with access to mezzanine balcony. Systemic failures in in…
76y · Male·Multiple organ failure due to sepsis with peritonitis and pancreatitis, secondar…
A 76-year-old man died from multiple organ failure following an ERCP procedure for gallstone removal. The procedure itself was appropriate and uneventful. Post-operatively, he developed severe abdominal pain and a CT sca…
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