538 results for “observation”
Three deaths with different primary causes: James Unicomb - acute toxicity due t…
Combined inquest into three deaths at Psyche South Clinic involving treatment failures: James Unicomb (22, 2005) from multi-drug overdose after naltrexone implant; Michael Poole (48, 2008) from ruptured aneurysm post-Rap…
24y · Male·aspiration of gastric contents due to or as a consequence of drug toxicity follo…
… containing excess medication supplies), lack of formal risk assessment documents, inconsistent nursing observations without proper documentation, and crucially, failure to engage Andrew's designated next-of-kin as his …
78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…
78-year-old woman with severe COPD and type 2 respiratory failure underwent elective melanoma surgery at a private day hospital (North Lakes Day Hospital) despite being classified as ASA 4 (unsuitable for day surgery). T…
0y · Female·Mechanical asphyxia due to or as a consequence of overlaying while bed-sharing d…
…ecution was unsafe due to maternal fatigue, absence of safety instructions, and inadequate frequency of observations. Three similar deaths across Queensland hospitals highlighted systemic policy gaps and inconsistent im…
36y · Male·Ligature strangulation
…reventability factors included: unsupervised laundry access (subsequently changed to locked with direct observation), lack of CCTV coverage in laundry (though coroner accepted direct supervision superior to camera), and…
21y · Female·drowning
…s in poor conditions with arm's-length supervision, dedicated surface watch personnel solely engaged in observation, and structured dive site risk assessment.
55y · Female·Cardiac tamponade due to haemopericardium due to acute ruptured myocardial infar…
…ent. The patient was discharged the next morning without appropriate cardiac enzyme testing or extended observation despite having chest pain and ECG changes following the procedure. She died at home 16 hours later from…
18y · Female, female, male·Caitlin: suicide by hanging; Talieha: suicide by hanging; William: suicide by tr…
Three adolescent patients (aged 18 at death) died by suicide within four months of the Barrett Adolescent Centre (BAC) closure in January 2014. Caitlin had complex mental health needs including bipolar affective disorder…
51y · Female·Multiple injuries sustained from a fall from the top floor of a multi-storey car…
Justine Painter, aged 51, died from multiple injuries sustained jumping from a multi-storey carpark while an inpatient at Royal Perth Hospital (RPH). She had severe treatment-resistant schizoaffective disorder, command h…
26y · Male·Ligature compression of the neck (Hanging)
Scott Davidson, a 26-year-old recently sentenced prisoner with paranoid schizophrenia, died by suicide in Casuarina Prison on 5 June 2000. Following sentencing to 9 years imprisonment, he was transferred to Casuarina Pri…
36y · Female·Complications of pneumonia and pulmonary emphysema with bullae formation; respir…
A 36-year-old woman with congenital chest wall abnormality, scoliosis, and difficult intubation history presented to a rural hospital with community-acquired pneumonia and sepsis. She had multiple 'red flag' indicators o…
63y · Male·ruptured abdominal aortic aneurysm
…ds after the patient's death, including rewriting the Emergency Department notes, changing the Recovery-Observation Chart, and altering vital sign recordings in a deliberate attempt to make the patient appear less ill t…
43y · Male·Multi-organ failure with coagulopathy secondary to acute exacerbation of chronic…
A 43-year-old man with a colloid cyst of the third ventricle presenting with progressive headache was admitted for planned endoscopic surgery. Surgery was delayed from Friday to Monday due to unavailability of specialist…
0y · Male·Complications following forceps delivery
…(2) subgaleal haemorrhage risk was high (APGAR <7 at 5 min, prolonged labour, multiple pulls) yet scalp observations were delayed due to CPAP bonnet obscuring assessment; (3) early recognition of SGH would have allowed …
0y · Female·dehydration
…sh the true frequency of fluid losses (at least 8 nappy changes), and dismissed the mother's concerning observations about sunken/dark eyes. He failed to consider hypernatraemic dehydration where skin turgor testing is …
40y · Male·Ligature compression of the neck in circumstances of being hanged
…nts focused on transfer rather than diagnosis or treatment. He was transferred from protective Muirhead observation cells to a non-BDRP compliant general prison cell after only 2 days, where he was found hanged from a s…
19y · Male·hypoxic brain injury following asphyxia due to hanging
Jordan Kirkwood, a 19-year-old male, died by hanging on 30 April 2019 after being admitted to a newly established community-based mental health program (MHHITH) on 3 April 2019. He presented with depression, cannabis wit…
26y · Male·ligature compression of the neck (hanging)
…y disorder and functional distress did not qualify him for psychiatric care; (4) the inadequacy of ARMS observations when staff were understaffed and had competing priorities; (5) the critical need for a tiered-care mod…
47y · Male·Aspiration pneumonia due to or as a consequence of coronary atherosclerosis
…ow oxygen readings with falsely high ones after mask replacement. A junior enrolled nurse provided sole observation while the senior nurse largely disengaged. When deterioration became evident at 2am (oxygen saturation …
53y · Male·fentanyl and oxycodone toxicity
…moving essential clinical information; failure to recognise clinical deterioration despite clear family observations of respiratory depression and profound drowsiness; and prescription of slow-release oxycodone (OxyCont…
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