89 results for “blood pressure monitoring”
74y · Male·Pericarditis post aortic valve surgery with large pericardial effusion leading t…
… day 10 post-surgery. At the rehabilitation facility, he developed progressive signs of deterioration: low blood pressure, elevated heart rate, respiratory distress, and low oxygen saturation overnight on 18-19 December…
56y · Male·Ischaemic Heart Disease and Coronary Artery Atherosclerosis
…at-risk patients even with atypical symptoms; document clinical reasoning thoroughly; ensure vital signs monitoring; recall patients for recommended cardiac surveillance. The coroner emphasised importance of thorough his…
77y · Female·Complications following a recent fracture and surgical repair of the right hip i…
…ent aimed at hypotension may have contributed to pulmonary/cardiac fluid overload evident at autopsy. (6) Pressure sores developed rapidly preoperatively and remained painful. The case illustrates that elderly patients w…
38y · Female·Streptococcus Group A Septicaemia (Post Partum-Puerperal Sepsis)
…ical warning signs including repeated elevated temperatures (38.7°C at 6:50am), severe abdominal pain, low blood pressure (80/60 at ~4:45pm), and low urine output, she was never prescribed antibiotics during her 23-hour…
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
… 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadequate urine output monitoring (no urinary catheter despite critical illness and acute kidney injury); delayed and sub-optimal antibiot…
6y · Male·Global cerebral ischaemia secondary to perinatal asphyxia
…arean section for obstructed labour and fetal distress. Key clinical lessons include: (1) continuous CTG monitoring should have been initiated immediately on arrival given documented decreased fetal movements in the week…
2y · Male·Cardiorespiratory arrest in a young child with opioid (morphine) toxicity
…l failures included: no fasting instructions despite using an opioid that causes vomiting; no continuous monitoring of oxygen levels or vital signs; and discharge from the clinic while still deeply asleep, less than 1.5 …
83y · Male·pneumonia and severe acute respiratory distress syndrome caused by Legionella ba…
…ber targeting aspiration rather than atypical organisms; (5) inappropriate triage and lack of vital sign monitoring. Early diagnosis and appropriate broad-spectrum antibiotics on 16 September afternoon would likely have …
62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (su…
…ion and IVC involvement. Multiple intraoperative factors contributed to poor outcomes: late recognition of blood loss, delay in activating massive transfusion protocol, loss of central line preventing vasopressor admini…
0y · Male·severe hypoxic ischaemic encephalopathy secondary to uterine rupture
… Mansfield returned at approximately 1.50pm and detected signs of possible uterine rupture: abnormally low blood pressure and low fetal heart rate. Emergency transfer to Busselton Hospital occurred; emergency caesarean …
50y · Male·gastrointestinal haemorrhage; haemorrhage from cystic artery post laparoscopic c…
A 50-year-old man died from gastrointestinal haemorrhage involving both a cystic artery and duodenal defect following laparoscopic cholecystectomy. Over five days post-surgery, he developed repeated episodes of hypotensi…
41y · Female·Intracerebral haemorrhage secondary to Posterior Reversible Encephalopathy Syndr…
…1-year-old woman five days post-caesarean delivery, presented to emergency with frontal headache, elevated blood pressure, proteinuria, abnormal liver function and lower limb oedema. She was admitted under general physi…
28y · Female·Anaphylactic reaction to anaesthetic drug (suxamethonium), with underlying coron…
A 28-year-old woman died during routine dental extraction under general anaesthesia at a regional hospital. Despite competent initial airway management, she developed severe respiratory distress immediately after inducti…
21y · Female·Multiple injuries sustained from being struck by a train; death by suicide while…
Alana Goldsmith, a 21-year-old woman with long-standing anorexia nervosa, died by suicide on 22 July 2011 after stepping in front of a train at Summer Hill Railway Station. She was admitted to Wesley Eating Disorder Clin…
Female·Verris Dawn Wright: septic shock due to small bowel ischaemia secondary to small…
Two joint inquests examined failures in recognising clinical deterioration in rural hospital patients. Mrs Wright, 86, presented with abdominal pain and a low temperature (early sepsis), but staff did not escalate when s…
29y · Male·Cardiac arrhythmia in the context of alcohol withdrawal and chronic alcohol misu…
…le with timely, adequate management. Key clinical lessons: alcohol withdrawal requires frequent clinical monitoring and reassessment; lack of improvement is itself a warning sign; severely withdrawing patients may need h…
38y · Male·Aspiration pneumonia
Scott Hambly, a 38-year-old life prisoner with dilated cardiomyopathy, epilepsy, and schizophrenia, died from aspiration pneumonia at Wolston Correctional Centre in December 2018. He was identified as needing cardiology …
33y · Male·Longstanding atheromatous coronary artery disease with severe stenosis and cardi…
A 33-year-old Aboriginal man died in custody from longstanding atheromatous coronary artery disease with cardiac hypertrophy. On presentation to the prison clinic with non-specific symptoms (headache, throat pain, arm an…
75y · Female·septic complications following surgical resection of duodenal ampullary adenoma
…surgery at an under-resourced private hospital without multidisciplinary team input; poor post-operative monitoring and fluid balance documentation; failure to recognise septic shock and respond appropriately; delayed re…
22y · Female·Sudden Arrhythmic Death Syndrome
…pertension without documentation of her cardiac findings or adequate follow-up arrangement. WADS monitored blood pressure only once post-discharge. No cardiology referral was made despite episodes suggesting pre-syncope…
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