88 results for “central monitoring”
69y · Female·Septic shock due to biliary peritonitis as a consequence of laparoscopic cholecy…
A 69-year-old woman died of septic shock following bile leak complications after laparoscopic cholecystectomy. Critical failures included: (1) inappropriate transfer to low-dependency unit on post-op day 1 despite consul…
Toxicity from intravenous caesium, DMSO, and other substances administered as pa…
…e clinic operated in substandard conditions with inadequate clinical supervision, sterile protocols, and monitoring. The coroner referred Dr B., nurses Phasey and Baker to AHPRA, and the matter to the Director of Public …
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 identified multiple significant failing…
52y · Male·Hanging
…tem at Pan Pacific Hotel was newly established (28 March 2020) with inadequate systems for assessing and monitoring mental health risks. Critical gaps included: no formal mental health screening on arrival, no risk strat…
77y · Female·Complications following a recent fracture and surgical repair of the right hip i…
…remained painful. The case illustrates that elderly patients with borderline organ reserve require close monitoring, lower threshold for infection suspicion, and protocolized perioperative care.
21y · Female·Multiple organ failure as a result of overwhelming Streptococcus pyogenes (Group…
Sara Hampel, 21 years old, died from sepsis caused by necrotising fasciitis (Group A Streptococcus) on 14 October 2011, presenting 8 days post-partum with severe leg pain and multiple signs of sepsis. Critical failures i…
31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)
…lement promised intensive drug rehabilitation; inadequate case management and risk assessment; failure to centrally control Schedule 8 medication (methadone tablets), which were extensively stockpiled by another residen…
20y · Male·Multiple injuries from fall from height
Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, died from multiple injuries after impulsively jumping an 8-metre wall at a hospital ambulance bay on 5 November 2019. He was in custo…
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