89 results for “blood pressure monitoring”
81y · Male·pneumonia due to traumatic internal bleeding of the chest wall sustained in fall…
…sed fall on 6 June 2021, sustaining a right-sided chest wall haematoma. Staff found him at 7:40am with low blood pressure and bruising; his doctor was contacted at 11:00am and an ambulance called at 3:00pm when chest sw…
Female·Hypoxic ischaemic encephalopathy following hypovolaemic shock and multi-organ fa…
…upport. The coroner emphasized the need for improved neonatal observation policies with clear vital sign monitoring triggers, staff education in recognizing blood loss, and robust escalation procedures. The Area Health S…
24y · Male·Multiple organ failure due to or as a consequence of severe thermal burns
…RNH) including obsolete ventilation (bellows anaesthetic machine rather than modern ventilator), lack of monitoring equipment, limited laboratory capacity, and inability to manage complex burns; (3) delayed recognition o…
49y · Female·Hypoxia due to complications following incision and drainage of a right buttock …
A 48-year-old woman with multiple comorbidities (diabetes, COPD, chronic kidney disease, ischaemic heart disease) died following complications of anaesthesia during incision and drainage of a buttock abscess. Critical fa…
22y · Female·Traumatic brain injury (diffuse axonal injury with skull fractures) secondary to…
…ad in the Northern Territory. She had consumed 15-20 cans of beer over approximately 10 hours, achieving a blood alcohol level of 0.12% at hospital admission. She had been awake most of the previous night four-wheel dri…
11y · Male·Sepsis
… from sepsis on 20 June 2022. He presented to Rosebud Hospital ED on 14 June with fever, vomiting, and low blood pressure, was discharged with a viral diagnosis. He re-presented on 15 June appearing critically unwell bu…
63y · Male·Right cerebral infarction caused by infusion of medication via central venous li…
…he arterial line, causing right cerebral infarction. The clinician relied on absence of pulsatile flow and blood colour to confirm placement but failed to perform manometry, transduction, or blood gas assessment despite…
1y · Female·Dilated cardiomyopathy
…as reasonable, the failure to reassess when clinical improvement did not occur was critical. Key failures: blood pressure was never recorded despite tachycardia (170 bpm) and tachypnoea (60/min) beyond 99th centile; no …
57y · Male·Head injury from fall; with coronary atherosclerosis and complete heart block wi…
…n, medications affecting mobility). While individual interventions were implemented (bed position, fluid monitoring, increased observations), these were not coordinated as part of a documented falls prevention plan. The …
51y · Male·combined effects of dilated cardiomyopathy with myocardial fibrosis and prescrip…
… sleep observations documentation failed to record respiratory status as required by policy; (3) cardiac monitoring protocols were actually exceeded standards; (4) the combination of antipsychotic cardiotoxicity, undiagn…
33y · Male·Decompensated congestive cardiac failure complicating acute myocardial infarctio…
… on day 2 was an error in cardiogenic shock, and the decision should have been reviewed and cancelled when blood pressure fell critically. Advanced monitoring in ICU with inotropic support (dobutamine) and consideration…
84y · Male·general inanition on a background of end-stage dementia and a fractured neck of …
…in extreme heat, requiring sedation and restraint. On 28 March 2019, he fell while sitting on a bed during blood pressure monitoring, sustaining a left neck of femur fracture. Surgery occurred 72 hours after anticoagula…
0y · Male·multifactorial with severe hypoxia/hypotension which occurred in the background …
…ound, though this didn't change surgical management. Critical gaps included: absence of continuous fetal monitoring while mother waited in anaesthetic bay (CTG cannot function without power source); inadequate communicat…
58y · Male·Pulmonary thromboembolism complicating right calf deep venous thrombosis
…ain and dyspnea; correctly apply risk stratification tools; admit patients with new cardiac symptoms for monitoring; recognize that small PEs may only cause symptoms on exertion.
17y · Female·Multi System Failure following acute onset (Acute Diabetic Ketoacidosis) Diabete…
Lee Rebecca Halford, a 17-year-old girl, died of acute diabetic ketoacidosis (DKA) following undiagnosed Type 1 diabetes. She initially presented to a GP with vomiting on 27 February 2007, diagnosed with gastroenteritis.…
3y · Female·complications of Influenza B viral infection
Three-year-old Caitlin Cruz presented to a medical centre unwell and collapsed, requiring resuscitation. She was transferred by ambulance to Children's Hospital at Westmead but critical information about her collapse and…
55y · Male·Cardiac hypertrophy with significant conditions contributing: coronary artery at…
Eric Lewis Wobona, a 55-year-old Aboriginal man with extensive cardiovascular risk factors including congestive cardiomyopathy, coronary artery disease, hypertension, diabetes, and previous amputation, died of acute hear…
75y · Male·multifactorial causes on a background of ischaemic heart disease, generalised va…
Robert Bischard, a 75-year-old man with multiple complex comorbidities including coronary artery disease, chronic kidney disease, and diabetes, died five days after elective right total knee replacement surgery. The coro…
56y · Male·Hypoxia and cardiac arrest with contributing conditions of Ischaemic Heart Disea…
…ntable due to failures in pre-operative assessment, choice of anaesthetic technique, and intra-operative monitoring and response. Systemic improvements including enhanced pre-operative protocols, high-risk patient flaggi…
73y · Male·metastatic carcinoma of the lung with palliation
…ms. The coroner identified missed opportunities for optimal follow-up during annual health assessments and blood pressure reviews over the subsequent years. However, she concluded this omission did not affect cancer dev…
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