88 results for “blood screening”
61y · Male·Multiple injuries due to motor vehicle collision (driver)
… included undiagnosed sleep apnea with interrupted sleep (refusing CPAP therapy), cannabis use detected in blood, evidence of habitual speeding, and poor logbook compliance. The coroner accepted that fatigue, speeding, …
33y · Male·Longstanding atheromatous coronary artery disease with severe stenosis and cardi…
…he presentation was atypical and the underlying disease was not previously detected despite prior health screening.
45y · Male·Intra-abdominal haemorrhage due to ruptured spleen due to splenomegaly due to ci…
Hayward Rasmussen, a 45-year-old man with cirrhosis and severe splenomegaly, died from intra-abdominal haemorrhage due to ruptured spleen while in custody. He collapsed in prison after sustaining possible rib injuries fr…
63y · Male·Hypoxic ischaemic brain injury and pneumonia complicating cardiac arrest in a ma…
…ns (diazepam, olanzapine, droperidol, promethazine, chlorpromazine). Critical failures included: no ECG or blood tests performed in ED despite high-risk medication exposure; lack of communication to psychiatric unit sta…
49y · Male·Acute blood loss from a single incised injury to left forearm
Jeremy Edward Chandler, a 49-year-old first-time prisoner, died by suicide in Melbourne Assessment Prison 36 hours after admission. He had been convicted of serious charges and remanded in custody pending sentencing. Des…
Female·Sepsis in the setting of a lotus birth
A premature female neonate born at 36+5 weeks via emergency caesarean section developed sepsis and died at 2 days of age. She had been delivered with lotus birth (cord left attached to placenta) and vaginal seeding (mate…
1y · Female·Obstructive sleep apnoea occurring in the context of significant, unrecognised h…
…dentify these risk factors, misunderstanding hospital policy as applying only a 2300g weight threshold. No blood glucose monitoring was performed despite Neonatal Hypoglycaemia Management Guidelines explicitly listing S…
76y · Male·metastatic prostate cancer with terminal palliative care
Kevin John Keath, aged 76, died from metastatic prostate cancer while serving a life sentence at Casuarina Prison. He received holistic, compassionate, and appropriate healthcare throughout his incarceration, including r…
57y · Male·Complications of opioid (hydromorphone and morphine) toxicity and incised wounds…
Leslie Hawkins, aged 57 with dementia and significant medical comorbidities, died from opioid toxicity and incised wrist wounds as part of a suicide pact with his terminally ill wife. Mrs Hawkins, diagnosed with advanced…
63y · Male·metastatic rectal carcinoma
…ay 2017 (ED assessment missed large rectal mass despite examination). Annual health reviews, faecal occult blood testing, and weight monitoring were not performed. Had colonoscopy been offered and accepted in 2015, tumo…
20y · Female·Head injuries sustained in motor vehicle accident
… include: cannabis impairment may not be apparent to clinicians or police officers from observation alone; blood testing protocols must include drug screening for all seriously culpable drivers in fatal crashes, not jus…
31y · Male·Pulmonary thromboembolism arising from deep vein thrombosis
Adam David McKay, a 31-year-old geologist, died from pulmonary thromboembolism arising from deep vein thrombosis on 23 January 2003. He had recently completed extensive long-haul flights to West Africa and returned on 13…
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…
53y · Male·Acute myocardial infarction due to triple vessel atherosclerosis and thrombosis …
A 53-year-old man with chest pain on exertion presented to his GP in March 2022. Initial investigations (blood tests, chest X-ray) were ordered but follow-up was delayed until July 2022. A cardiology referral was made…
25y · Male·Aspiration pneumonia secondary to methadone toxicity
…e monitoring; and a wellbeing check that recorded only foot movement. Recommendations focus on improving screening protocols, cross-agency information sharing, clearer methadone dosing frameworks, and more robust prison…
31y · Male·hanging (self-inflicted)
…n isolated management unit (Unit 7) on 1 June after displaying agitation and aggressive behaviour during a blood sugar check. Nursing staff recognised his deteriorating mental state and arranged urgent psychiatric revie…
Female·Betty: cardiac arrhythmia complicating heart failure due to consequences of past…
…9 and September 2020. All three deaths were preventable through better primary health care coordination, screening, and anticoagulation management. Key systemic failures included fragmentation between Gidgee Healing (Ab…
30y · Male·Haemopericardium caused by ruptured dissecting thoracic aortic aneurysm
Joel Frigo, 30-year-old with Marfan's syndrome, presented to a regional hospital with chest pain and was diagnosed with a chest infection/pleurisy. He died from a ruptured dissecting thoracic aortic aneurysm with haemope…
38y · Male·Acute drug toxicity due to clozapine-induced cardiac arrhythmia
…psychiatric hospital to prison on 20 July 2007 with stabilised clozapine therapy monitored through regular blood tests. Key factors contributing to the fatal outcome were: (1) cessation of smoking upon transfer to priso…
7y · Female·multiorgan failure due to fulminant sepsis (Streptococcus pyogenes)
…ior nurse recorded abnormal vital signs (fever, tachycardia, tachypnoea) but did not complete the sepsis screening tool (PARROT chart) before being called away; and staff failed to escalate care despite repeated parenta…
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