10y · Male·sepsis (fusobacterium necrophorum) complicating right otitis media
… meaningful intervention; lack of coordinated response between agencies; and absence of prosecution for educational neglect despite legal provisions.
3y · Female·Drowning
Lauren Harris, aged 3 years, drowned in a non-compliant backyard swimming pool in September 2008 after gaining access to the pool enclosure while unsupervised. The pool barrier failed to meet Australian Standards due to …
1y · Male·Head injury in the setting of labour
…ing a potentially difficult delivery. The RWH and the College were recommended to review guidelines and educational practices regarding detection and management of impacted fetal heads.
60y · Female·Peritonitis due to anastomotic leak following subtotal colectomy for treatment o…
60-year-old woman died from septic shock due to anastomotic leak following subtotal colectomy for synchronous bowel cancers. Early postoperative bronchospasm complicated clinical assessment, leading focus on respiratory …
Male·Hypoxic-ischaemic encephalopathy due to meconium aspiration syndrome
…ot performed despite multiple indications (pre-eclampsia, suspicious admission CTG, meconium-stained liquor risk); water birth was allowed despite being contraindicated in severe pre-eclampsia; and the caesarean section …
9y · Male·asthma - acute episode of asthma which became increasingly resistant to Ventolin
…nderstanding (not just providing information), documenting and escalating parental denial of diagnosis as a risk factor, taking parental concerns about discharge seriously, and ensuring individualised education for famil…
83y · Female·Pneumonia complicating rib and pelvic fractures sustained in the setting of mult…
…iatric symptoms to specialist services earlier, poor inter-facility communication, and lack of formal falls risk assessment on admission.
…ng required Hazard Reduction Certificates; RFS officers provided only informal advice without checklists or risk assessment; the owners possessed minimal firefighting equipment; the burn site bordered high-fuel-load nati…
multi-drug toxicity (opioids, heroin, benzodiazepines, prescription drugs)
This inquest examined six opioid-related deaths in NSW occurring in May 2016, with causes ranging from heroin and fentanyl toxicity to multi-drug overdoses. The coroner identified multiple preventable factors: inadequate…
Sudden Unexplained Death of an Infant (SUDI) in an unsafe sleeping environment; …
…), and Baby S (5 weeks) all died from sudden unexpected death in infancy (SUDI) associated with co-sleeping risk factors including parental intoxication, soft mattresses, heavy blankets, prematurity, and multiple co-slee…
14y · Male·gunshot wound to the head
Andrew Scott Anderson was a 14-year-old boy placed in Department of Child Safety care following his father's physical assault. He had a longstanding history of behavioral difficulties, ADHD, depression, and substance use…
7y · Male·Joshua died due to a combination of physical entrapment of his head which occlud…
…is mobility and inability to call for help, neither medical nor nursing staff had appreciated this level of risk. Lessons include: team nursing requires explicit documented task assignment; high-dependency children need …
88y · Female·Acute on chronic renal failure due to dehydration on a background of Lewy body d…
…. June 2020 blood tests showed mild hypernatraemia (sodium 149 mmol/L), a biochemical marker of dehydration risk, but this was not recognised or acted upon by her GP. A three-day food and fluid chart in July 2020 showed …
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