95 results for “clinical instability”
49y · Male·combined drug toxicity
…mphetamine, and cannabis). He was managed on a Community Treatment Order in the community by an Intensive Clinical Outreach Team. While the coroner found his care reasonable overall, the finding identifies that greater p…
48y · Male·Haemophilus influenzae bronchopneumonia in the setting of alcohol and methadone …
…xed address and lived in a tent. His GP prescribed methadone takeaway doses despite clear indicators of instability: homelessness, frequent intoxication at consultations, known mixing of methadone with alcohol and canna…
71y · Male·Multi organ failure due to post-operative bleeding following endoluminal thoraci…
…ominal aortic aneurysm at St Vincent's Private Hospital on 1 December 2008. He developed post-operative instability with hypotension, metabolic acidosis, acute renal failure and coagulopathy. Re-angiography at 10pm on 2…
77y · Female·haemorrhagic diathesis due to warfarin toxicity
…ly 1 mg to avoid prior over-correction experiences, rather than temporarily cessating or using vitamin K. Clinical lessons: INR should be monitored every 2–3 days during instability; warfarin management in elderly, isola…
25y · Female·Neck compression secondary to hanging
CM, a 25-year-old woman experiencing depression, anxiety, and substance misuse, died by suicide while in an intimate partner relationship characterised by documented family violence. She presented to hospital multiple ti…
42y · Male·Cardiac arrest following hypoxic ischaemic encephalopathy, likely due to E.coli …
…n the evening of 3 July 2016. Although prescribed 1:1 nursing care criteria were met (restless, agitated, clinically unstable), he received 1:2 care. Medical staff underestimated his agitation severity due to poor commun…
15y · Male·Hypoxic ischaemic brain injury, due to hanging
… no observable signs of depression or self-harm risk to family, school staff, or his doctor. The critical clinical lesson concerns the delayed communication of school absences to parents—the school failed to contact his …
48y · Female·Neck and chest injuries sustained in the incident with the cherry picker. Mechan…
…ed; and no personal protective equipment worn. The machine was fundamentally unsuitable for this purpose. Clinical lessons include recognition that workplace injuries causing crush asphyxia, pericardial tamponade, and mu…
34y · Male·Long drop hanging resulting in complete decapitation
Jason Jenkins, aged 34, died by suicide (long drop hanging resulting in complete decapitation) on 17 June 2006, approximately 6 weeks after discharge from psychiatric admission on a Community Treatment Order. He had a 15…
40y · Male·Haemorrhage from gunshot wound to chest
Lee Andrew Kennedy, a 40-year-old man with a history of mood instability, migraines, and medical treatment through a GP and psychiatrist, died from a gunshot wound to the chest…
22y · Male·Hypoxic ischaemic encephalopathy complicating hanging
…l phobia, died by suicide via hanging on 17 March 2020, four days after discharge from hospital. Critical clinical gaps were identified: after presenting to ED on 6 March 2020 with high suicide risk, he left without bein…
14y · Female·Neisseria meningitidis infection (meningococcal septicaemia)
…ncy Department on 4 December 2007 with high fever (40°C), headache, vomiting, myalgia, and haemodynamic instability (hypotension, tachycardia, tachypnoea)—all signs of serious bacterial infection. Hospital doctors misdi…
52y · Male·Multiple injuries and immersion leading to hypoxic brain injury and pneumonia
…ntarily to Casey Mental Health Service from 30 December 2008 to 16 January 2009. The coroner examined Y's clinical management and discharge planning. Key issues identified: inadequate forensic psychiatric assessment of Y…
19y · Male·Traumatic asphyxia
…ia after falling from a turf harvester while reversing. He was struck and crushed underneath the machine. Clinical lessons include: (1) traumatic asphyxia causes death within minutes through chest compression preventing …
9y · Male·Disseminated melioidosis
…spital on 23 February. Despite appropriate intensive care, he died within 12 hours. The coroner found his clinical care was appropriate and followed Queensland Health guidelines. Melioidosis is rare in children without i…
38y · Male·Organizing pneumonia with loculated pleural effusion in the setting of drug use …
…neumonia with loculated pleural effusion in the setting of methadone and benzodiazepine use. The critical clinical failure was lack of communication between his two treating doctors: Dr R. (ORT prescriber) and Dr H. (men…
17y · Male·Unascertained in the setting of volatile substance abuse
… contact with child protection and youth justice systems, and was living in youth accommodation. Critical clinical lessons include: (1) the risks of volatile substance abuse and sudden sniffing death were inadequately co…
25y · Male·Multiple system failure and ingestion of sodium nitrite
BT, a 25-year-old man with bipolar affective disorder and long-standing depression, died from intentional sodium nitrite ingestion while an inpatient in the Behavioural Assessment Unit at Royal Melbourne Hospital. He pre…
86y · Male·coronary and cerebral atherosclerosis with significant conditions of fractured l…
Mr. Stanley Charles Anderson, aged 86, died at Gympie General Hospital from coronary and cerebral atherosclerosis, precipitated by injuries sustained in a fall at a nursing home. While transferring from a bath trolley to…
34y · Male·mixed drug overdose (heroin, methadone, codeine, diazepam, nitrazepam, oxazepam …
…chiatric assessment or addiction management. He died the following day from mixed drug overdose. Critical clinical lessons include: (1) higher threshold for ED discharge of overdose patients with polysubstance use and so…
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