538 results for “observation”
68y · Male·Ischaemic small and large intestine complicating cardiogenic shock in the settin…
Ignac Lecek, 68, with hypertension and gout, collapsed in custody and died of ischaemic bowel complicated by cardiogenic shock in the setting of ischaemic heart disease. He complained of feeling ill on 2 October while in…
83y · Male·pneumonia and severe acute respiratory distress syndrome caused by Legionella ba…
An 83-year-old man died from pneumonia and respiratory distress caused by Legionella bacterium. He presented with abdominal symptoms and was initially misdiagnosed as having aspiration pneumonia rather than community-acq…
31y · Male·hanging (self-inflicted)
Darryl Walker, a 31-year-old Aboriginal man with chronic schizophrenia and diabetes, died by hanging in Port Lincoln Prison on 2 June 2003. He had been transferred to an isolated management unit (Unit 7) on 1 June after …
38y · Female·peritonitis with septic shock secondary to perforation of the gastrointestinal t…
A 38-year-old woman in persistent vegetative state following anoxic encephalopathy from anaphylaxis during surgery died from peritonitis caused by perforation at the gastrostomy stoma site. The perforation likely occurre…
26y · Female·multiple injuries sustained as a result of being struck by a motor vehicle on th…
A 26-year-old woman with schizo-affective disorder, detained under the Mental Health Act, absconded from a psychiatric hospital and was fatally struck by a vehicle on a freeway. Clinical concerns include: (1) inadequate …
37y · Male·Acute Aspiration Pneumonitis following on Quetiapine Ingestion
Paul John Long, a 37-year-old man with chronic schizoaffective disorder and alcohol dependence, died on 4 November 2002 from acute aspiration pneumonitis following quetiapine overdose. After presenting to Avro Clinic in …
26y · Male·Neck compression from hanging
A 26-year-old man died by hanging in his correctional centre cell on 26 October 2011. He had a history of mixed personality disorder, anxiety, opiate dependence and previous suicide attempt (age 13), but was not assessed…
0y · Male·unascertained
…nication between hospital, child protection, and prison services was needed before discharge; (2) close observation of maternal drowsiness due to medication combinations (methadone, gabapentin, diazepam) should have pro…
42y · Female·Pneumonia, underlying severe cerebral palsy
Rachel Piskun, aged 42, died from pneumonia complicated by severe cerebral palsy. She had severe disabilities requiring 24-hour care in supported accommodation. During a September 2021 hospitalization, compression stocki…
33y · Male·Opiate toxicity
A 33-year-old man with previously unrecognized obstructive sleep apnoea was admitted with severe headache. The treating physician prescribed a complex regimen of escalating opiate doses including both slow-release (MS Co…
35y · Male·hanging
…as cancelled and not rebooked; Mr Thomas's interstate records were unavailable); rapid de-escalation of observations without alternative safety mechanisms may be unsafe; and prisoners explicitly stating they won't discl…
75y · Female·hypovolaemic shock following uncontrolled blood loss from mini-liposuction stem …
A 75-year-old woman with advanced frontal lobe dementia died from hypovolaemic shock following uncontrolled bleeding after an unproven stem-cell liposuction procedure. Critical failures included: failure to cease anticoa…
27y · Female·Septicaemia secondary to Neisseria meningitides infection
Naomi Williams, a 27-year-old Wiradjuri woman, died from meningococcal septicaemia on 1 January 2016. She presented to Tumut Hospital in the early hours with generalised aches and pains while pregnant. Despite vital sign…
17y · Male·intra-abdominal haemorrhage complicating partial pancreatectomy for traumatic pa…
Andrew Gilmore, a 17-year-old fit and well boy, suffered traumatic pancreatic rupture from a football injury on 9 May 2009. Distal pancreatectomy was performed at Alfred Hospital on 11 May. He was discharged to Hospital …
46y · Female·Hepatic encephalopathy due to decompensated Child-Pugh C cirrhosis and meningiti…
This combined coronial finding examines three deaths at the Centre for National Resilience (CNR), a COVID-19 quarantine facility in Howard Springs. Ms Dick died from rapidly progressive melioidosis. David Hardy died from…
31y · Female·incised wounds to the neck and arms
A 31-year-old illustrator with a recent onset of acute depression and suicidal ideation attended Fremantle Hospital ED via ambulance after GP referral on 12 May 2014. She had made a suicide attempt at a beach two days ea…
8y · Male·ischaemic bowel due to strangulated small bowel obstruction secondary to congeni…
…yed paediatric involvement; poor pain assessment not accounting for autism; missed opportunity to score observations using CEWT leading to delayed Code Blue activation. Senior clinician oversight was absent. The coroner…
75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis
…escalate or insist on urgent transfer. The patient remained at Glen Innes overnight without appropriate observations or antibiotics. On 1 April, increasing confusion was noted ("off with the fairies") but not recognised…
74y · Female·Multiple injuries sustained when struck by train
A 74-year-old woman with borderline personality disorder, depression, anxiety and type 2 diabetes died by suicide after absconding from Fiona Stanley Hospital Emergency Department. She had been on extended psychiatric ad…
Unknown·Ms Fensom: influenza A (H1N1 2009, pandemic swine flu) with myocarditis causing …
Two deaths from H1N1 influenza in 2009. Ms Fensom (41) died from myocarditis complicating swine flu after inadequate recognition and management of persistent hypotension at Millicent Hospital. Her condition required esca…
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