95 results for “clinical instability”
76y · Male·exsanguination secondary to pulmonary aortic fistula and thoracic aorta aneurysm…
…orrhage secondary to rupture of his thoracic aorta into the adjacent lung (pulmonary aortic fistula). Key clinical lessons include the challenges of managing complex cases combining severe depression with inoperable life…
71y · Male·Combined effects of ischaemic and valvular heart disease
…ound the initial detention lawful, psychiatric and medical care appropriate, and made no recommendations. Clinical lesson: patients with florid psychosis and poor insight into physical illness present management challeng…
54y · Male·hypoglycaemic encephalopathy complicating multiple injuries in a man with chroni…
…e definitively determined, though police investigation suggests possible involvement of an associate. Key clinical lessons include the critical importance of recognising hypoglycaemia as a medical emergency in diabetic p…
68y · Male·Complications of a witnessed airway obstruction from food bolus in a man with dy…
…patient and family repeatedly requested 'normal' food despite education about risks. The coroner found no clinical prevention opportunities; Northern Health had provided appropriate swallowing assessments, dietary advice…
18y · Male·Multiple injuries due to train over-run
… and impulsive aggression. However, he appeared happy to friends that evening and had family support. Key clinical lesson: young people with substance abuse, relationship instability, and aggressive outbursts require com…
42y · Male·unascertained
…ther than requiring antipsychotic medication. He received depot antipsychotic treatment for years despite clinical doubt about its necessity. No effective rehabilitation for alcohol abuse was engaged. He was last seen af…
75y · Female·Complications of multiple injuries sustained when struck by a car (pedestrian)
…ultiple surgeries. Despite maximal treatment over three weeks, her condition declined with haemodynamic instability and hypoxia. The collision occurred in poorly lit conditions at dusk; the deceased wore dark clothing a…
53y · Female·Unascertained (presumed drowned)
…rtraline and diazepam for anxiety management, but Smith declined initial antidepressant therapy. Critical clinical lessons include: recognising catastrophic thinking and functional limitations as suicide risk factors; en…
FV Cassandra: vessel capsize likely whilst retrieving snagged trawl net from sea…
…. FV Dianne capsized in moderate seas; cause uncertain but may involve drogue rope fouling propeller or instability from wave action. Both vessels lacked automatic EPIRB activation and life raft deployment failures occu…
56y · Female·Acute combined drug toxicity
… bathroom while intoxicated, becoming wedged in a confined space that contributed to positional asphyxia. Clinical lessons include: careful monitoring of patients transitioning between opioids; recognising that medicatio…
81y · Female·Severe cardiogenic shock complicating cardiac surgery
…ardiogenic shock following elective aortic valve replacement complicated by intraoperative haemodynamic instability and inadequate postoperative ICU management. The surgery involved emergency coronary artery bypass graf…
97y · Male·Complications of a fractured left neck of femur (operated), sustained in a fall
A 97-year-old man with vascular dementia, visual impairment, gait instability and multiple falls risk factors fell during a supervised outing from his aged care facility and sustain…
33y · Male·Decompensated congestive cardiac failure complicating acute myocardial infarctio…
A 33-year-old man with morbid obesity and steroid dependency presented with chest pain and light-headedness. Initial GP assessment missed acute coronary syndrome despite ECG changes on second visit. ED correctly diagnose…
45y · Male·unascertained
… a suicide attempt, but his body was never found. The coroner could not determine the cause of death. Key clinical lesson: the rapid discharge of a high-risk patient with severe ongoing psychosocial stressors after only …
42y · Male·drowning from immersion in rough ocean waters
… loss of consciousness. The coroner found drowning was preventable through mandatory life jacket use. Key clinical lessons: proper personal protective equipment (life jackets) in high-risk environments saves lives; physi…
48y · Male·gunshot wounds to the right thigh and abdomen with fatal hemorrhage
A 48-year-old man with severe chronic pain, alcohol dependence, and mental health issues called police stating he was armed with knives and wanted to be shot. Despite being extensively supported by health services that d…
68y · Male·Pulmonary thromboembolus secondary to deep vein thrombosis
…jor surgery. Warfarin anticoagulation was appropriately ceased due to bleeding risk from the cancer and instability during chemotherapy. After surgery, he received appropriate short-term VTE prophylaxis with clexane. Ho…
23y · Female·chronic hydrocephalus with brain swelling
… criticised as substandard, expert evidence confirmed the hydrocephalus was asymptomatic and undetectable clinically. No investigations (CT, lumbar puncture, X-ray) would have been indicated. Systemic issues at the hospi…
59y · Male·Hanging
… 2019. He was bail-refused for domestic violence charges and held for only two days before his death. Key clinical issues identified: delayed provision of his antidepressant Pristiq (due to incomplete release of informat…
47y · Female·insulin and mixed drug toxicity, the result of actions undertaken by the decease…
…st treatment appropriate. However, the psychologist's failure to comply with a coroner's order to produce clinical records for nearly a year unnecessarily hampered investigation. The coroner noted the psychologist did no…
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