332 results for “emergency patient transfer”
57y · Male·Ischaemic Heart Disease
…nsion, hypercholesterolaemia and chronic airways disease died of acute myocardial infarction whilst being transferred by ambulance from a mental health facility to hospital. He was an involuntary patient admitted for bip…
75y · Male·ruptured abdominal aortic aneurysm
A 75-year-old man with hypertension, diabetes, and smoking history presented to a regional emergency department with right lower quadrant abdominal pain, back pain, groin pain, nausea, and vomiting. He was…
22y · Female·bowel obstruction due to faecal impaction
…m Sir Charles Gairdner Hospital (SCGH). By 28 October, despite worsening pain and clinical deterioration, transfer was not arranged until 28 October evening when her condition became critical. The coroner found the proce…
18y · Male·Hypoglycaemic hypoxic-ischaemic encephalopathy, due to massive liver necrosis, d…
…ers about the severity or duration of symptoms. He was found in a hypoglycaemic coma the next morning and transferred to hospital where he died four days later from massive hepatic necrosis. Key clinical lessons: the dia…
89y · Female·pneumonia and acute renal failure following a fractured right femur due to a fal…
… 17 December 2015. A mobility assessment in October 2015 had determined she required a full hoist for all transfers due to inability to weight-bear safely, yet on the day of the incident two experienced carers used a sta…
83y · Male·Aspiration pneumonia
…ument hydration monitoring during the prescribed 12-hour observation period; family requests for hospital transfer were delayed; and communication with family about diagnosis was inconsistent. The patient was transferred…
31y · Male·Lymphocytic Myocarditis in association with Acute Pericarditis (viral origin, ae…
…ober. Initial investigations suggested infection but lacked specific diagnosis. A Priority III (elective) transfer to Royal Perth Hospital was arranged, later upgraded to Priority II (doctor-accompanied) as he deteriorat…
56y · Female·aspiration pneumonia complicating seizure in a woman with trisomy 21 and Alzheim…
…with Down syndrome and Alzheimer's disease died from aspiration pneumonia following a seizure while being transferred by sling from bath to bed in her disability care facility. She was transferred to hospital where imagi…
63y · Male·ruptured abdominal aortic aneurysm
… practitioner until 4:20pm—a delay of over 7 hours. The Royal Flying Doctor Service was not contacted for transfer to Perth until 7:25pm, a further 3+ hour delay. He died at 9:05pm from a ruptured abdominal aortic aneury…
30y · Female·Mixed drug toxicity (propranolol, duloxetine and codeine)
…owing referral by her private psychiatrist for acute suicidal ideation. Key clinical lessons include: BPD patients may not disclose suicide plans despite appearing functional; the balance between safety monitoring and t…
76y · Male·Multiple organ failure due to sepsis with peritonitis and pancreatitis, secondar…
…t/duodenum with free abdominal fluid. The surgeon opted for conservative management without reviewing the patient or escalating care. Deterioration continued overnight with peritonitis developing. A second review at 02:…
76y · Female·Head injury comprised of subdural haematoma, subarachnoid haemorrhage with brain…
…markedly at 9pm with signs of increased intracranial pressure. Critical delays occurred in escalating and transferring her to a neurosurgical centre. The regional hospital's junior doctor failed to escalate deterioration…
39y · Male·respiratory failure and cardiac arrest
…lowing midazolam administration. Despite these serious findings suggesting respiratory compromise, he was transferred to the mental health ward where acute medical support was unavailable. During admission processes ther…
65y · Male·escherichia coli urosepsis
…of septic shock was present (hypotension 84/60 mmHg progressing to 60/40 mmHg). Critical delays occurred: transfer to high-dependency care was not made until 6:45am despite explicit medical direction for 5-minute observa…
49y · Female·Unascertained; most likely cardiac abnormality
… medically cleared after 7.5 hours with improving Glasgow Coma Scale (13→15) and normal vital signs, then transferred to the SAAPU where she was found unresponsive at 1am. Cause of death remained unascertained despite au…
25y · Male·ligature compression of the neck (hanging)
A 25-year-old man with dexamphetamine-induced psychosis died by suicide while an involuntary psychiatric patient. He was transferred from a locked to an open ward on 19 April 2013 after appearing to improve clinically.…
71y · Male·Saddle pulmonary embolus as a consequence of deep venous thrombosis in the right…
… under Mental Health Act detention for severe depression with psychotic features. On 28 July 2000, he was transferred to Royal Adelaide Hospital where right calf DVT was identified on ultrasound but no anticoagulation wa…
84y · Male·Head injury - left lateral convexity acute subdural haematoma with 2mm midline s…
…bilitation unit after a fall at an acute hospital. He had been assessed as high falls risk and required a patient sitter at the acute hospital, but this critical need was not communicated during transfer. Without sitter…
13y · Female·cerebral oedema and infarction secondary to extensive subdural empyema
…een at a GP and Noarlunga Health Service. When she returned with left leg weakness, she was appropriately transferred to Flinders Medical Centre where Dr T. performed an excellent clinical assessment, identified intracra…
66y · Female·acute necrotising haemorrhagic mediastinitis
…orated oesophagus was considered but Mrs Pratt was kept at the small rural hospital overnight rather than transferred urgently to the Royal Adelaide Hospital. Transfer occurred next morning but by then mediastinitis had …
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