88 results for “central monitoring”
55y · Female·Unascertained
…o adverse findings were made against Cook. The case highlights gaps in psychiatric facility policies for monitoring patient physical wellbeing during routine visual observations, particularly when sedating medications ar…
57y · Male·Multiple Organ Failure and Intra-Abdominal Haemorrhage following Cholecystectomy
…; early recognition of post-operative renal failure is critical; adequate medical coverage and ICU-level monitoring are essential for complex post-operative recovery; the deceased was not intubated despite respiratory fa…
35y · Male·Head injury sustained in a bicycle accident
…liance on self-reporting by drivers, absence of mandatory reporting by medical practitioners, and lack of centralised information-sharing between healthcare and licensing authorities. The coroner emphasised that drivers…
62y · Female·Haemorrhage caused by abdominoperineal excision of the rectum
A 62-year-old woman died of uncontrollable haemorrhage following an abdominoperineal excision of the rectum (APER) at a remote hospital. The coroner found the operation itself was inappropriate: performed for undiagnosed…
27y · Male·multiple organ failure due to the consequences of multiple gunshot wounds to the…
Mahmoud Houri died aged 27 in custody from multiple organ failure, a consequence of gunshot wounds sustained in 2002. The inquest examined whether appropriate care was provided on 21 August 2008 when he presented with vo…
32y · Female·Cardiac arrest due to hypoxia caused by dynamic hyperinflation arising from comp…
A 32-year-old woman with Sponastrime Dysplasia (a rare genetic bone disorder) died during elective bariatric surgery. She had undiagnosed subglottic stenosis (airway narrowing) and tracheobronchomalacia. Critical clinica…
42y · Female·Pneumonia, underlying severe cerebral palsy
…ner highlighted systemic neglect of people with disability in hospital settings and recommended improved monitoring of care quality for this vulnerable cohort.
26y · Male·Multi-organ failure due to pneumococcal septic shock
A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…
75y · Female·cardiac arrest in the context of aortic stenosis (moderate to severe), coronary …
A 75-year-old woman with significant cardiac history (aortic stenosis, coronary artery disease, left ventricular hypertrophy) underwent elective ankle ulcer debridement surgery. She developed refractory hypotension post-…
41y · Male·Respiratory depression caused by alcohol and morphine poisoning
Anthony Mark Perry, aged 41, died in police custody at Rockhampton watch house on 23 March 2010 from respiratory depression due to morphine and alcohol. He was arrested for breaching a domestic violence order after drink…
36y · Male·Ligature strangulation
Duke Schafer, 36-year-old prisoner, was murdered by fellow inmate Carl Bloomfield in May 2020 at Woodford Correctional Centre. Bloomfield strangled Schafer in an unsupervised laundry area during a period when officers we…
25y · Male·Combined drug toxicity
… care with regular case coordination; benzodiazepines in patients with addiction history require careful monitoring and restricted dispensing.
45y · Female·Multisystem organ failure secondary to acute liver failure associated with parac…
Elsa Harrington, a 45-year-old woman, died from acute liver failure secondary to paracetamol toxicity in November 2002. She was admitted post-hysterectomy with bowel obstruction and underwent adhesion surgery. Following …
89y · Male·combination of biochemical consequences of colonic pseudo-obstruction and faecal…
An 89-year-old man with multiple comorbidities including previous colon cancer died from faecal impaction and stercoral colitis. He resided in a residential aged care facility (RACF) where staff failed to recognize that …
60y · Male·Hypertensive heart disease with chronic fatty liver as other significant conditi…
David Duggan, a 60-year-old man with hypertensive heart disease and cardiomegaly, was admitted to Caloundra Hospital on 10 January 2007 for management of severe acute back pain caused by a suspected L3/4 disc herniation …
Unknown·Traumatic injuries caused by the collapse of the Alpine Way fill embankment trig…
…capability to manage parks and urban communities; RTA examination of slope assessment systems; continued monitoring of the Alpine Way; systematic record-keeping of instability incidents; and amendments to building codes …
17y · Female·Combined drug toxicity (heroin, codeine, methadone, benzodiazepines)
…or takeaway dosing, mandatory safe storage education and provision of locked boxes, real-time electronic monitoring of controlled drug dispensing, and consideration of buprenorphine as a safer alternative.
0y · Female·Hypoxic ischaemic encephalopathy caused by multiple factors including lung abnor…
… causation remains uncertain—the underlying lung abnormality and undetected apnoea during transfer appear central. Clinicians should ensure delivery plans are followed, follow institutional neonatal resuscitation guidel…
26y · Female·Pulmonary embolism as a consequence of dislodged deep vein thrombosis
…t involvement needed, multi-agency planning essential for complex psychiatric cases, DVT prophylaxis and monitoring critical in immobilised patients with obesity, and robust handover of imaging results imperative.
58y · Male·Multiple injuries occasioned in a motor vehicle accident (broken neck, ruptured …
…from multiple injuries sustained in a motor vehicle accident on 18 December 2004 at Barrow Creek, NT. The central clinical issue was the inadequate emergency assessment and management by Registered Nurse Ann Paulus at t…
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