63 results for “missed approach”
49y · Male·Injuries received in aviation accident
…s certificate had expired in 2003 but he flew anyway; he failed to monitor mandatory radio frequencies and missed critical weather updates; he approached at night despite Visual Flight Rules restrictions; and fuel levels…
83y · Female·Pulmonary thromboembolism due to aortic stenosis (recent transcatheter aortic va…
…ual heart failure symptoms, the failure to conduct planned electrophysiology review before discharge was a missed opportunity. The coroner found that a pacemaker would have offered only small survival benefit from pulmon…
42y · Female·Traumatic right subdural haematoma
A 42-year-old woman died from a traumatic right subdural haematoma sustained on 22 January 2015. She was found unresponsive at home with severe head and facial injuries after falls. Critical delays in medical assessment …
24y · Female·multi organ failure due to meningococcal septicaemia
24-year-old woman presented to ED with fever (40.1°C), headache, myalgia and mild photophobia. RMO Dr R., relatively inexperienced (5 weeks in Australia), examined her thoroughly but focused on excluding meningitis throu…
43y · Male·Bilateral pulmonary thrombo-emboli; contributory factors included obesity, coron…
Paul Harris, a 43-year-old Aboriginal man, died from bilateral pulmonary emboli while hospitalized at Hay District Hospital. He presented in September 2019 with pneumonia and Q fever (occupational exposure from kangaroo …
46y · Female·Hypoxic brain injury in the setting of plastic bag asphyxia
…responsive with the bag over her head. Critical failures included: insufficient staffing coverage led to a missed hourly observation at 12.00pm when two LDU nurses were assisting in the HDU; failure to perform a required…
15y · Female·hanging
…portunities to provide concrete support (discharge from hospital, placement breakdowns, homelessness) were missed. No suitable suspension alternatives existed for vulnerable girls. DCJ failed to adequately support inform…
79y · Male·Respiratory failure due to haemothorax and hospital-acquired pneumonia due to mu…
A 79-year-old man with extensive comorbidities died following multiple falls in residential aged care. He was identified as high falls risk on admission but experienced inadequate falls prevention after a second fall on …
66y · Female·urinary tract infection with contributing hypertensive heart disease, diabetes m…
Rita Ann Broadway, 66, died from urinary tract infection on 2 January 2015, one day after presenting to Modbury Hospital Emergency Department with vaginal pain and signs of infection. She had a long-term indwelling cathe…
37y · Male·self-inflicted gunshot wound to the head and neck
Matthew Lothian, aged 37, died from a self-inflicted gunshot wound to the head and neck on 6 January 2021 in Wollongong. He was on medical escort from custody when he seized the firearm from Correctional Services Officer…
54y · Male·Bowel ischaemia resulting from acute thrombosis of superior mesenteric artery an…
…ave advised continuing clopidogrel and potentially avoiding tranexamic acid, or reconsidered the surgical approach. The coroner found that appropriate pre-operative management would have likely prevented stent occlusion …
69y · Female·Septic shock due to biliary peritonitis as a consequence of laparoscopic cholecy…
…; (5) incomplete handover of antibiotic administration status to theatre; (6) inadequate nursing care with missed vital signs and failure to escalate MEWS score of 3. Expert evidence confirmed antibiotics initiated immed…
50y · Male·Complications of right buttock necrotising fasciitis secondary to chronic right …
… a patient with prior drug dependence fell far below accepted standards. No medical expert supported this approach. Proper chronic pain management should have involved oral sustained-release formulations, specialist cons…
6y · Male·cardiopulmonary arrest on a background of earlier cardiac arrests and resuscitat…
Austin Facer, a 6-year-old boy, suffered multiple cardiac arrests at school on 21 October 2019, initially resuscitated successfully, but died during transfer preparation to a higher-level hospital that evening. Autopsy r…
59y · Male·head injuries
Roger Schnelle, a 59-year-old accountant, died from head injuries sustained through intentional self-harm while involuntarily detained at Nolan House mental health facility in April 2021. He developed sudden onset severe…
62y · Female·Hypovolaemic and cardiogenic shock (hysterectomy) in the context of cardiomegaly…
… (lower limit acceptable); unrecognised right ventricular hypertrophy with probable pulmonary hypertension missed on pre-anaesthetic evaluation; inadequate pre-operative optimisation planning; no specialist cardiology or…
19y · Male·acute bacterial meningitis with secondary cerebritis (meningococcus)
Adam Fabre, a 19-year-old with fever, severe headache, neck pain, muscle pain (10/10), vomiting, tachycardia and blanching rash, presented to Casey Hospital ED at 3:45am on 14 July 2006. Despite expressing clear concern …
multi-drug toxicity (opioids, heroin, benzodiazepines, prescription drugs)
…s, including expanded supervised injection facilities, better prescriber education, and decriminalisation approaches, many of these deaths were preventable.
41y · Male·Stab wound to the chest
…Men's behaviour change programs were unavailable due to Jack's transience. The coroner identified multiple missed opportunities for holistic, proactive service responses to assess and address safety concerns and underlyi…
54y · Male·aspiration pneumonia caused by multiple drug toxicity
Paul Lau, aged 54, died from aspiration pneumonia caused by opioid toxicity following ACL reconstruction surgery. The death resulted from a prescribing error where anaesthetist Dr K. inadvertently prescribed a 100mcg/hou…
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