73 results for “pulmonary aspiration risk”
26y · Female·Pulmonary embolism as a consequence of dislodged deep vein thrombosis
Naomi Smith, aged 26, died from pulmonary embolism caused by dislodged deep vein thrombosis while in ICU at Royal Darwin Hospital. She had complex…
70y · Male·complications arising from craniofacial resection and orbital exenteration for r…
…ry, complications, and comorbidities. The death resulted from surgical complications in the context of high-risk surgery for an aggressive malignancy.
79y · Male·Bronchopneumonia and acute bronchiolitis
…tial diagnosis even with non-specific symptoms, value of secondary medical assessment before discharge, and risks of diagnostic anchoring on gastrointestinal causes. A chest x-ray two days prior showed no consolidation; …
45y · Female·combined drug (tapentadol, nortriptyline, venlafaxine, codeine, oxycodone, queti…
…er classified the death as misadventure rather than suicide. Clinical lessons include: GPs prescribing high-risk opioids must conduct regular risk-benefit assessments and monitor for substance abuse; timely provision of …
71y · Male·Complications of metastatic squamous cell carcinoma (terminal palliation)
…cal care included: failure to complete annual health assessments after 2015; inadequate follow-up of a high-risk squamous cell carcinoma (SCC) lesion identified in April 2019 that was never re-excised; unacceptable delay…
81y · Male·multi-organ failure complicating multiple right-sided rib fractures due to a fal…
…pecialist assessment, intensive pain management, and transfer to major trauma centres due to high mortality risk from complications including respiratory failure, pneumonia, and multi-organ failure.
55y · Female·acute necrotising bronchopneumonia
…face-to-face assessment or investigation despite colleagues expressing serious concern for serious cardiopulmonary pathology. Critical clinical lesson: MQ's symptoms were consistent with severe bronchopneumonia yet she …
1y · Female·unrecognised oesophageal intubation
A 19-month-old girl died from unrecognised oesophageal intubation during anaesthesia for finger laceration repair. The anaesthetic team failed to recognise multiple clinical indicators of tube misplacement: absence of pe…
48y · Female·Ischaemic brain injury secondary to toxicity to tramadol and temazepam
A 48-year-old woman died from ischaemic brain injury caused by overdose of tramadol and temazepam. She was found unresponsive at home on 10 October 2009 after consuming these medications. Her family and GP Dr D. failed t…
19y · Male·unexpected arrhythmogenic event leading to a fall from height, blunt force head …
… or CPVT) that could not have been identified pre-training. Key preventable factors included lack of proper risk assessment of the tunnel obstacle, absence of timely defibrillation (delayed by water hazard), and difficul…
46y · Female·hypoxic ischaemic encephalopathy complicating cardiorespiratory arrest in the se…
…patients with asthma and hay fever, particularly those uncontrolled on reliever-only therapy, faced highest risk. Better preventer medication compliance, asthma action plans, allergy testing, and remaining indoors during…
77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…
…sive fluid resuscitation earlier; (2) senior clinician review warranted overnight given complexity and high-risk comorbidities; (3) ICU consultation should have occurred during weekend deterioration; (4) central venous p…
35y · Male·Cardiorespiratory arrest in the setting of acute agitation and physical and chem…
Hizir Ferman, aged 35, died at Middleton Prison following forcible extraction from his room by SESG officers using CS gas and physical restraint. He was held prone with hands cuffed behind him, a shield on his back, and …
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