91 results for “severe pulmonary hypertension”
85y · Female·ischaemic heart disease due to stenosis of coronary bypass grafts
…ked coronary bypass graft causing acute myocardial infarction. While preventability is uncertain given her severe cardiac disease, key failings included: absence of nursing staff at GP consultation, no documented action …
76y · Male·Coronary atherosclerosis in the context of obesity, obstructive sleep apnoea, an…
A 76-year-old man with significant comorbidities including severe obstructive sleep apnoea, obesity, aortic stenosis, and ischaemic heart disease died from acute coronary a…
81y · Female·Multisystem failure in the setting of hyponatraemia secondary to chronic malnutr…
…d woman with chronic schizophrenia, heart failure, and dementia died from multisystem failure secondary to severe malnutrition and hyponatraemia. Over four years, her son (Medical Power of Attorney) progressively restric…
87y · Female·combined effects of ischaemic heart disease and chronic obstructive pulmonary di…
Epenesa Pahiva, 87-year-old resident with dementia at an aged care facility, suffered severe chemical burns from inappropriate bleach treatment prescribed by dermatologist Dr B.. The coroner found th…
48y · Female·Ischaemic brain injury secondary to toxicity to tramadol and temazepam
…onship with the family compromised his clinical judgement. The patient was eventually admitted to ICU with severe brain damage and died ten days later. Earlier hospital admission might have changed the outcome, though ir…
77y · Male·complications of haemothorax and hypotension following drainage of pleural effus…
77-year-old male died from complications of haemothorax and hypotension following drainage of pleural effusion post-coronary bypass surgery, in the setting of pre-existing renal impairment and diabetes. During pleural ta…
8y · Male·prematurity-associated lung and bowel disease
Daniel Wright was a premature infant (born at 24 weeks) with multiple complex medical needs including chronic lung disease, developmental delay, and failure to thrive. He died aged eight months from prematurity-associate…
78y · Female·cardiorespiratory failure, ischaemic and hypertensive heart disease together wit…
Barbara Francis, a 78-year-old resident with dementia at Pearl Supported Care in the dementia unit (Dinah), was punched by another resident (Mr A) on 4 September 2018 and fell backward onto her right hip, sustaining an o…
68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…
… wrong order, leaving both medications active. The patient received both drugs before transfer, leading to severe bleeding. Key lessons: Electronic Medical Records (EMRs) with poor usability design contributed critically…
Unknown·COVID-19 infection with various comorbidities as contributing factors
…use residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical management under a Hospital-in-the-Home model. Key failures in…
76y · Female·hospital acquired pneumonia, multiple organ dysfunction and small bowel obstruct…
… acute renal failure and dangerously high potassium levels (8.1 and 7.6 mmol/L). Despite clear evidence of severe illness requiring urgent transfer to a tertiary centre, she remained at the rural hospital for approximate…
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