83 results for “general anaesthesia and intubation”
34y · Male·hypoxic-ischaemic encephalopathy following laparoscopic bariatric surgery with i…
Andrea Lambropoulos, a 34-year-old man with morbid obesity, sleep apnoea, and ischaemic heart disease, died fol…
67y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …
David Fensom, 67, underwent elective fundoplication for hiatus hernia and reflux on 21 September 2010. He developed severe right-sided abdominal pain post-operatively. A laparoscopy…
8y · Male·Septic shock consequent on burst appendix with peritonitis
… 2009 but the diagnosis was missed. The next day, his treating doctor correctly diagnosed ruptured appendix and referred him urgently to hospital. At Liverpool Hospital ED, critical failures occurred: the referral lette…
57y · Female·Intra-abdominal Haemorrhage following Appendectomy, with contributing factor of …
A 57-year-old woman with COAD, hypertension, and unrecognized severe coronary atherosclerosis presented with appendicitis. Surgery was performed by an unsup…
17y · Male·Multi-organ failure with terminal fungal sepsis (Aspergillus) on a background of…
…estigating acute severe abdominal pain on 13 May 2011. Despite classic peritoneal signs noted at 9:30 pm (generalised tenderness, guarding, rebound tenderness), no imaging or surgical review occurred until 14 May, resul…
33y · Female·Raised intracranial pressure secondary to thrombosis of the superior sagittal, t…
…mbosis (CVT) was not pursued despite radiologists recommending MRI. Poor communication between radiologists and neurosurgeons meant the on-call neurosurgeon was given an incomplete clinical picture, leading to conservat…
32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity
…ear-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with sedat…
24y · Male·Multiple organ failure due to or as a consequence of severe thermal burns
…esthetic machine rather than modern ventilator), lack of monitoring equipment, limited laboratory capacity, and inability to manage complex burns; (3) delayed recognition of abdominal compartment syndrome due to insuffi…
44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)
…icians. Inadequate fluid resuscitation, failure to escalate to ICU promptly, incomplete antibiotic therapy, and poor clinical handover allowed the patient to deteriorate to cardiac arrest. Expert opinion suggested that …
75y · Male·Acute cardiac failure due to mitral valve disease (surgically treated)
Arthur Lawrence Smith, 75, underwent successful mitral valve repair and coronary artery bypass grafts at TPCH on 2 August 2004 and was discharged 5 days later. On 19 August, his w…
33y · Female·Hypoxic ischaemic encephalopathy complicating mixed drug toxicity
…o 10mg three times daily without in-person review. She was found unresponsive on 27 May with severe hypoxia and died from hypoxic-ischaemic encephalopathy. Critical failures included: ambiguous communication between doc…
61y · Female·multi organ failure due to abdominal sepsis
…ior antibiotic exposure—Tazocin reuse may have been suboptimal given prior prolonged exposure; (3) medical handover between surgical and ICU teams must explicitly communicate critical medication history; (4) rapid clini…
40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…
…te at a correctional facility, died on 27 December 2008 from hypoxic brain injury following cardiac disease and severe pneumonia. Critical failures in prison healthcare were identified. On 17 December, Mr. Magro submitt…
56y · Male·Internal blood loss, complications arising from laparoscopic cholecystectomy
…ternal bleeding after laparoscopic cholecystectomy due to critical systemic failures in post-operative care and diagnosis. Following hypotension at 7:30pm, nursing staff failed to follow escalation protocols and a docto…
70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia
70-year-old Sean Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner i…
43y · Male·Multi-organ failure with coagulopathy secondary to acute exacerbation of chronic…
…o unavailability of specialist equipment. Over Saturday, he deteriorated with worsening headache, vomiting, and nausea—classic signs of increased intracranial pressure. The neurosurgeon rescheduled surgery for Sunday mo…
77y · Female·Complications following a recent fracture and surgical repair of the right hip i…
… fibrillation, aortic stenosis, chronic renal impairment, emphysema) on Warfarin sustained a femur fracture and underwent ORIF on day 3 of admission (19 Nov 2009). Key clinical lessons: (1) Admission urinalysis was not …
Hypoxic-ischaemic encephalopathy following ventilatory failure/cardiac arrest (R…
…ive days post-hip replacement with undiagnosed coronary artery disease; cardiac ischaemia triggered by pain and hypertension was misdiagnosed as asthma. Both patients posed high anaesthetic and post-operative risks and …
62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (su…
…cell renal cell carcinoma. The decision to operate was reasonable based on available preoperative pathology and imaging, made by experienced surgeons after multidisciplinary review. However, the tumour proved inoperable…
16y · Male·mid-gut volvulus and bowel obstruction, leading to ischaemic bowel and related c…
…-old with Down syndrome, presented to Bathurst Base Hospital on 30 September 2016 with acute abdominal pain and vomiting. Despite clear clinical signs—including a lactate of 7.2 mmol/L (grossly abnormal), faeculent vomi…
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