185 results for “triage assessment”
76y · Male·advanced atherosclerotic and hypertensive cardiovascular disease
… died at home the next morning from acute coronary syndrome. Coroner identified multiple failures: delayed triage, unsupervised student assessment, failure to recognise elevated troponin, non-compliance with serial tropo…
19y · Female·asphyxiation
…priately escalated to ACIS. However, she was classified as 'non-urgent' and never received a psychiatric assessment. A two-page document expressing sophisticated suicidal intent was described by expert psychiatry as extr…
47y · Male·pericardial tamponade secondary to ruptured dissecting thoracic aortic aneurysm …
Salvatore Accardo, a 47-year-old with previously diagnosed Marfan syndrome, died from pericardial tamponade secondary to ruptured dissecting thoracic aortic aneurysm. He presented to Austin Hospital ED on 22 February 200…
36y · Male·infective endocarditis
…itis on 25 March and again on 12 May, but the referral to Princess Alexandra Hospital general medicine was triaged as non-urgent (category B, 30-day appointment). The patient deteriorated rapidly in late May with pneumon…
0y · Male·cardiac arrhythmia associated with surgically corrected congenital heart disease
… care was the critical clinical error, compounded by poor documentation and lack of adherence to available triage guidelines requiring doctor notification for all infants under 6 months.
36y · Female·multiple blunt force injuries sustained after intentional self-infliction by fal…
…fter only 2 days despite concerning MSE findings; failed referral to community mental health services when triage nurse misinterpreted Fiona's response; and police/ambulance responders lacking adequate mental health trai…
43y · Male·Multiple injuries sustained in a motor vehicle accident (driver)
Cameron Boyes, a 43-year-old man, died in a high-speed motor vehicle collision after his engagement was called off. He had contacted mental health services on 23 March 2019 reporting suicidal ideation and sleep deprivati…
33y · Male·complications from blunt force trauma to head consequent upon being struck by a …
…ute methadone withdrawal presented with suicidal ideation on the morning of 11 February 2007. The Crisis Assessment and Treatment (CAT) Team assessed him at 5pm and concluded he was not suicidal, diagnosing drug withdraw…
20y · Male·gunshot wound to the chest
…found the shooting legally justified. Critical clinical lessons include: ensuring adequate mental health assessment and follow-up in young people with BPD and multiple suicide attempts; managing acute mental health crisi…
4y · Male·Severe rhabdomyolysis due to LPIN1 gene mutation
Tom Olive, aged 4, died from severe rhabdomyolysis caused by a rare LPIN1 gene mutation. Over 12 months before death, he presented with recurrent episodes of dark urine, muscle pain, and lethargy. Multiple GPs and a paed…
20y · Male·acute haemorrhage and blunt abdominal trauma
…nrecognised despite mentioning being hit in the guts and feeling winded. He was released without medical assessment and remained in bed at home until his deterioration at 4pm prompted hospital admission. Clinically, the …
29y · Male·ligature compression of the neck (hanging)
…ory and visual hallucinations, bizarre behaviour, and paranoid ideation following return from Bali. He was triaged as ATS 3 and assigned a 30-minute target, but faced a 9-hour wait due to ED overcrowding. Given 10 mg ola…
17y · Male·Hypoxic Ischaemic Encephalopathy Complicating Anaphylaxis
…t the ED, James developed wheeze and cough just before entry—a sign of recurrent anaphylaxis. However, the triage nurse assigned ATS Category 3 rather than Category 2; whether he was informed of the wheeze is disputed. W…
23y · Female·Unascertained
…aramedics' decision not to transport her was clinically inappropriate. The coroner found the paramedics' assessment complied with clinical guidelines; vital signs were normal, and expert evidence confirmed that even with…
23y · Female·multiple blunt force injuries from fall from height
… induced by cannabis use. She had attended Royal North Shore Hospital the previous day for mental health assessment and was discharged after evaluation by a mental health nurse and psychiatrist who considered her low ris…
29y · Female·peritonitis caused by ischaemia of the bowel due to gastrointestinal torsion (tw…
… delayed calling an ambulance despite hours of severe distress, the emergency department misclassified her triage category (Category 3 instead of Category 2), she was left on an ambulance trolley for two hours without pa…
43y · Male·Septic shock from streptococcus pneumoniae sepsis arising from streptococcus pne…
…m as Category 5, influenced by the patient's smoking and drinking history rather than objective clinical assessment. The patient was discharged and seen next morning at a clinic, where Dr G. appropriately diagnosed proba…
79y · Female·multiple injuries sustained in collision between semi-trailer and train
… ineffective coordination between emergency agencies, delayed or inappropriate decisions regarding patient triage and air transport, and a level crossing risk assessment system (ALCAM) that failed to identify this danger…
40y · Male·coronary artery atherosclerosis
…ly to hospital, he likely would have been present for resuscitation when the occlusion occurred. The phone triage failure to recommend emergency services was also problematic. Key lessons: radiating chest pain is a red f…
36y · Male·neck compression in the circumstances of hanging
…son. He contacted police and mental health services expressing distress but denying suicidal intent. NWMHS Triage's assessment was appropriate and psychiatric admission was not clinically indicated. The coroner found no …
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