538 results for “observation”
45y · Female·hypoxic brain injury following hemopneumothorax resulting from a stab wound to t…
…2004, discharged from hospital after initial stab wound assessment without chest X-ray or admission for observation. Wound to posterior chest was explored and stitched by Dr W. but pneumothorax risk not assessed. Two da…
25y · Male·Injuries sustained when struck by a train (suicide)
…igh risks including suicide/self-harm and absconding, yet the patient remained on Level 2 (30-minutely) observations rather than Level 3 (continuous or specialling) observations as required by the Observation Guideline.…
69y · Male·asphyxia by hanging
…ntable failures included: inadequate clinical handover not flagging psychiatric risk, lack of dedicated observation protocols for psychiatric patients on general wards, and absence of standardised absconder procedures. …
35y · Male·Hyponatraemia, with psychogenic polydipsia and schizophrenia/schizoaffective dis…
…ymptomatic. Key issues included: limited CCTV monitoring of non-RIT inmates; lack of clinical detail on observation requirements in the health management plan; correctional officers unaware that excessive water intake c…
24y · Male·Aspiration pneumonia secondary to drug abuse and overdose of multiple drugs
…me sedated. His mother contacted the mental health triage service; the practitioner advised half-hourly observations at home rather than hospital admission. The mother fell asleep at 3:30am after conducting checks. The …
74y · Male·Pericarditis post aortic valve surgery with large pericardial effusion leading t…
…tion overnight on 18-19 December. Nursing staff failed to follow escalation procedures despite abnormal observations falling within alert ranges on the Observation Response Chart. Staff attributed symptoms to post-opera…
46y · Male·congestive cardiac failure due to cardiomyopathy and coronary artery atheroscler…
…endency, and appropriate nursing assessment was conducted on arrival. However, critical deficiencies in observational practice emerged: cell guards conducted 15-minute checks inconsistently from a distance rather than i…
36y · Male·Alcohol toxicity from consumption of Listerine mouthwash
…ient at Bridgeview House mental health unit when found unresponsive at 7am on 15 December 2014. Nursing observations every 2 hours showed difficulty assessing his breathing, particularly at 5am. While staff knew Kevin u…
38y · Male·acute cardiac arrhythmia in a man with cardiomegaly, focal coronary atherosclero…
…y to perform pulmonary function testing during his April-May 2019 admission; failure to obtain physical observations on the evening of 7 June when the patient had calmed; and missing observation charts from midnight onw…
24y · Female·multiple injuries from jumping off Bulla Road overpass onto Tullamarine Freeway
…ent behaviour not weighted), delayed notification to police (1.35 hours after absconding), insufficient observation frequency following second absconding episode, and lack of structured monitoring for approved leave con…
59y · Male·head injuries
…ecorded him as "moderate" risk throughout. Critical failures included: inadequate escalation of nursing observations despite clear warning signs (threatening self-harm, attempted choking, concerning communications with …
73y · Female·Complications of lipoid pneumonia following the ingestion of shampoo, conditione…
…ous suicide attempt by hanging in hospital and requesting close monitoring, she was placed on 30-minute observation intervals. On 2 June 2023, nursing staff found her vomiting after she had ingested shampoo, conditioner…
Female·traumatic and hypoxic brain injury caused by numerous falls and self-beating of …
…seclusion in a mental health unit. Critical clinical failures occurred: she was not provided one-to-one observation during the first hour of seclusion as mandated by protocol, was observed only via darkened video monito…
87y · Female·intentional inhalation of tissue paper leading to upper airway obstruction and h…
…btaining reliable, detailed incident records to assess clinical deterioration; establishing appropriate observation frequencies when psychiatric symptoms change significantly; and ensuring staff understand that patients…
48y · Male·drowning
…staff awareness of his need for supervision. Clinical staff checked on him intermittently but no direct observation occurred. He left saying he needed air and subsequently entered the sea. The coroner found supervision …
57y · Male·Multiple injuries sustained by being struck by a freight train
…nt options for resistant psychosis—were contraindicated due to cardiac comorbidity. He was on 15-minute observations and waiting for transfer to aged care. The coroner found no deficiencies in psychiatric care, but iden…
53y · Male·Steven Hitchins: plastic bag asphyxiation; Shawn Gudge: hanging
…s in a Queensland mental health unit highlight systemic failures in environmental hazard management and observation practices. Steven Hitchins (age 53) died by asphyxiation with a plastic bag in 2014; Shawn Gudge (age 2…
28y · Male·neck compression due to hanging
…n 2 June 2011 using a canvas smock. He had made recent threats of self-harm and was placed under camera observation in G Division. The tragedy resulted from a fatally flawed camera monitoring system—the 'five in thirty …
30y · Female·Hypoxic brain injury due to mixed drug toxicity (vecuronium and atropine self-in…
…r antipsychotic medication was inadequate despite florid psychosis; (2) she required one-to-one nursing observation but was managed at lower observation levels; (3) critical clinical information (including her morning a…
30y · Male·methadone toxicity
…are included: inadequate vital sign monitoring (only 8 occasions during 6-day admission), no documented observations after Acuphase administration despite policy requirements, and nursing staff unaware that 15-minute vi…
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