95 results for “clinical instability”
36y · Male·multiple injuries consistent with a fall from a height
…essages on social media and stood on a cliff ledge. Police negotiators engaged him for several hours. Key clinical lessons emerge: (1) Communication barriers were present from the outset but not promptly escalated to com…
13y · Male·Self-inflicted (manner recorded as intentionally self-inflicted; specific method…
A 13-year-old boy with depression, migraine, school refusal and family instability died by intentional self-inflicted means. His general practitioner provided inadequate mental health as…
38 and 3y · Female and male·Stacey: hanging; Seth: undetermined causes (likely suffocation, drowning, or str…
…from childhood sexual abuse, killed her 3-year-old son Seth before taking her own life in March 2017. Key clinical lessons include: inadequate communication between Stacey's psychiatrist and general practitioner regardin…
31y · Male·Hanging
31-year-old male with borderline personality disorder, alcohol use disorder, and history of self-harm died by hanging. He had multiple presentations to emergency services and mental health services from March to July 202…
35y · Female·multiple injuries sustained in fall from sixth-floor balcony
… woman with bipolar affective disorder and schizophrenia, died by suicide at age 35 in November 2016. Key clinical lessons include: (1) the critical importance of continuity of psychiatric care during transitions between…
43y · Female·Hypoxic ischaemic brain injury resulting from alcohol and sodium valproate toxic…
… WBH delayed dialysis initiation by >24 hours despite clear indicators (cerebral oedema, cardiovascular instability, metabolic acidosis). Early intubation at PDH, prompt senior escalation, early toxicology consultation,…
1y · Male·Complication of burns and trauma to the mesenteric artery
…rs of unknown cause. The child deteriorated in a manner inconsistent with typical burn injuries. Critical clinical lessons include: (1) severe supervision failures by parents; (2) failure of government agencies (NSW and …
68y · Female·Sepsis (Enterobacter cloacae) due to peritonitis as a consequence of leaking per…
…on formal CT report); and transfer by single paramedic with nurse escort without RSQ consultation despite clinical instability. She arrested during ambulance transfer and died. Early recognition of sepsis, appropriate es…
64y · Male·Septic shock secondary to urosepsis (Pseudomonas and Stenotropomonas maltophilia…
…d troponin, hyperkalaemia, metabolic acidosis). The locum doctor and nurses failed to recognize sepsis or clinical deterioration. Critical errors included: misinterpreting elevated troponin as renal failure alone, not in…
36y · Male·Multi-organ failure complicating injecting drug use
… than deliberate self-harm, the lack of assertive post-discharge psychiatric follow-up represented a lost clinical opportunity. Clinical lessons: unplanned discharges require escalation protocols; assertive follow-up wit…
11y · Female·Complications of E. coli sepsis in association with intestinal obstruction due t…
Child R, an 11-year-old Aboriginal girl with congenital anorectal anomalies causing chronic severe constipation, presented to Halls Creek Hospital on 5 January 2017 with severe abdominal pain and vomiting. She died 12 ho…
40y · Male·haemopericardium complicating ascending thoracic aortic dissection
… review on a full-resolution screen did not occur. However, the presentation was atypical for dissection, clinical suspicion was justifiably low, and junior doctors could not be expected to diagnose this subtle radiologi…
33y · Female·Hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiop…
…erangements including hyponatraemia, and alcohol-related liver disease. Expert review identified multiple clinical and systemic failures: inadequate micronutrient replacement (particularly thiamine), unappreciated gross …
Jessica: disseminated intravascular coagulation following haemorrhage (subgaleal…
…r S. of deteriorating CTG findings, potentially allowing expedited delivery and reduced hypoxia exposure. Clinical lessons include: maintain high suspicion for subgaleal haemorrhage severity despite apparent haemodynamic…
61y · Male·cardiac tamponade caused by aortic dissection due to hypertension
Harry Coxell, a 61-year-old man with hypertension, presented to Blacktown Hospital with severe sudden-onset chest pain on 31 October 2006. The Emergency Department doctor, Dr H., assessed him as intermediate risk for isc…
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