215 results for “emergency triage”
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…
20y · Male·acute haemorrhage and blunt abdominal trauma
Adam Chandler, a 20-year-old university student, died from acute haemorrhage and blunt abdominal trauma 15.5 hours after sustaining a severe internal injury. He was hit with a heavy potted plant (approximately 20kg) whil…
22y · Male·Mixed Diflunisal and Buproprion (Zyban) toxicity
A 22-year-old man presented to Royal Adelaide Hospital's Emergency Department after taking approximately 110 Zyban (bupropion) tablets as a suicide attempt. Unknown to tre…
20y · Male·gunshot wound to the chest
…hasis on patient safety and sustained engagement; considering continuity of mental health care following emergency department discharge; recognizing the complex interplay of substance abuse, impulsivity, and mental illn…
45y · Female·Neck compression secondary to hanging
…ued prematurely despite her known nighttime deterioration; care coordination between services (psychiatric triage, community mental health, ED, police) was fragmented and unstructured; and reliance on external NDIS suppo…
23y · Female·Unascertained
Stacey Yean, 23, died of an unascertained cause after presenting with violent vomiting on 5 January 2016. Her family believed that if paramedics had transported her to hospital, she would have survived. The coroner exami…
48y · Male·Cardiac hypertrophy, combined with effects of gamma hydroxybutyrate and amphetam…
…end's house after drug ingestion and was found unresponsive hours later. The key clinical lesson is that emergency services received inaccurate information about substance use—the caller reported only alcohol intoxicati…
29y · Female·peritonitis caused by ischaemia of the bowel due to gastrointestinal torsion (tw…
…iple levels: carers at her group home 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 ambu…
0y · Male·Complications in association with fulminant sepsis in an infant (Streptococcus p…
Malakai Paraone, a seven-month-old infant, died from fulminant Streptococcus pyogenes sepsis and septic shock. Over three days, he was seen at three hospitals and a general practice clinic but sepsis was not identified. …
79y · Female·multiple injuries sustained in collision between semi-trailer and train
…oo late to stop. The collision exposed multiple systemic failures: inadequate training of train staff in emergency roles, absent or ineffective coordination between emergency agencies, delayed or inappropriate decisions…
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…
33y · Male·complications from blunt force trauma to head consequent upon being struck by a …
A 33-year-old man with long-standing substance abuse and acute methadone withdrawal presented with suicidal ideation on the morning of 11 February 2007. The Crisis Assessment and Treatment (CAT) Team assessed him at 5pm …
43y · Male·Septic shock from streptococcus pneumoniae sepsis arising from streptococcus pne…
David Crisfield, a 43-year-old immunosuppressed patient with COPD on Crohn's disease therapy, died from streptococcus pneumoniae septic shock. He presented to a rural hospital ED on 6 November 2007 with respiratory compr…
74y · Male·acute myocardial ischaemia related to stenosis of the right coronary artery
… presented to Launceston General Hospital ED on 24 February 2019 with fever, vomiting and dizziness. After triage at 6:27pm, he waited unattended for over 4 hours without further medical assessment or contact. At 11:10pm…
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 …
55y · Male·Cardiac tamponade due to ruptured aortic dissection (Type A) against a backgroun…
Rick Dickinson, a 55-year-old man, presented to St Andrew's War Memorial Hospital after experiencing severe central chest pain and lower back pain with numbness at the gym. The treating senior doctor failed to adequately…
40y · Male·coronary artery atherosclerosis
…e reported chest pains via the Custody Messaging System (CMS) to a prison nurse. The nurse, Sinead Finlay, triaged this as non-urgent based on the communication method and medium rather than clinical severity, arranging …
40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…
…ate hospital care, he died on 27 December. The coroner identified systemic failures: inadequate green form triage, poor escalation procedures, and deficient internal investigations. Key recommendations included immediate…
18y · Male·Multi organ failure due to sepsis from a Group A streptococcus infection
…ical clinical lessons include: (1) the dangerous Business Rule that discouraged vital signs measurement at triage was a systemic failure—full vital signs should be routine for all ED patients; (2) vital signs were not ta…
23y · Female·multiple blunt force injuries from fall from height
Grace Herington, 23, died from multiple blunt force injuries sustained in a fall from a highway off-ramp during an acute psychotic episode induced by cannabis use. She had attended Royal North Shore Hospital the previous…
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