538 results for “observation”
40y · Male·Unascertained; likely cardiac arrhythmia secondary to cardiomegaly and morbid ob…
…on. While this poor nursing care was not directly causative, it represented a failure in basic clinical observation and human dignity that contrasted with appropriate overall psychiatric treatment.
42y · Female·salt water drowning
…nificant lapses in nursing care quality and emphasized that detained patients require clearly specified observation protocols with proper documentation.
23y · Male·cerebral hypoxia secondary to strangulation from hanging by belt
…He was placed in the Low Dependence Unit (LDU) based on risk assessment. Nursing staff provided regular observations; early morning observation found no active suicidal intent. Later that day, he was found hanged by his…
Female·Verris Dawn Wright: septic shock due to small bowel ischaemia secondary to small…
…lation. Jasmyn Carter, 17, presented with fever and hypotension documented as 'emergency' on the Q-ADDS observation tool, but staff did not activate the required emergency response. She deteriorated overnight and died o…
48y · Male·Septicaemia in a man with a psoas abscess; Diabetes mellitis
…icularly given the critical importance of medication compliance and the undisclosed concerning clinical observation.
30y · Male·neck compression
…e clinical management by Forensicare including medication, psychiatric reviews, and placement in a high-observation unit following acute suicidal crisis on 21 June, he was transferred to mainstream accommodation on 23 J…
54y · Male·Cardiac arrest in a person with cardiac hypertrophy and generalised atherosclero…
…officers. Key clinical lesson: enhanced training on excited delirium syndrome risks, post-taser medical observation protocols, and taser restrictions for vulnerable populations (psychotic, intoxicated, mentally unwell) …
61y · Female·hypoxic brain injury following cardiac arrest due to neck compression due to han…
…icide attempt by overdose and was under a Mental Health Act detention order. Despite appropriate hourly observations and recent assessment showing no indication of imminent suicidal risk, she hanged herself within 35 mi…
32y · Male·ligature compression of the neck (hanging)
…nursing staff assessed him as high-risk but changed monitoring from one-to-one specialling to 15-minute observations based on his calm presentation. He was allowed to rest in a remote room while waiting for medical asse…
62y · Male·cardiac arrest complicating psychotic episode
…s had deteriorated into cardiac arrest, delaying CPR initiation. Critical failures included: inadequate observation while restraining (no clinician maintained head-of-stretcher position), failure to apply supplemental o…
32y · Male·hanging
…admitted following overdose and suicidal ideation, deemed high-risk, and placed on standard half-hourly observations. Critical admission documentation (risk assessment and nursing assessment) was not completed despite a…
85y · Female·ischaemic heart disease due to stenosis of coronary bypass grafts
…key failings included: absence of nursing staff at GP consultation, no documented action plan for close observation, delayed recognition of symptoms, poor fluid monitoring, and inadequate ambulance communication. Earlie…
16y · Female·upper airway occlusion due to aspiration of a foreign body (disposable latex glo…
…er care plan but not adequately communicated to all staff. While at the facility, she required constant observation but was left unattended in a playroom when carers attended to another child with higher-risk behaviours…
55y · Female·Unascertained
…s gaps in psychiatric facility policies for monitoring patient physical wellbeing during routine visual observations, particularly when sedating medications are administered.
76y · Female·aspiration of gastro-intestinal contents as a result of small bowel obstruction …
…ctually suffered small bowel torsion causing obstruction, not gastroenteritis. She was not admitted for observation despite the severity of her collapse. On return to the psychiatric facility, she deteriorated with repe…
27y · Male·suicide by hanging
…s needing urgent replacement since 2020 but were not replaced due to funding issues; grossly inadequate observation practices relying on CCTV rather than in-person contact, with only 4 documented face-to-face observatio…
40y · Female·hypoxic encephalopathy due to asphyxia from hanging
…expressing suicidal intent. Despite being assessed as high-risk with a management plan requiring hourly observations, she was placed in an open unit rather than high-dependency or closed unit. Critical failures included…
46y · Male·self-inflicted hanging
… expressed suicidal ideation and documented a near-hanging attempt on 8 December, the coroner found his observation regime was appropriate given apparent stabilisation and weekend leave. The coroner determined the death…
59y · Female·Toxicity to quetiapine
…Subsequently, the hospital locked LDU doors, requiring voluntary patients to request exit, and modified observation protocols based on individual risk assessment.
38y · Male·self-inflicted hanging
…rderline personality disorder diagnoses. Despite a prior suicide attempt on the same evening, an hourly observation regime was implemented rather than 15-minute intervals. Critical clinical lessons include: the need for…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.