185 results for “triage assessment”
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 …
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…
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…
5y · Female·Multiple injuries sustained in a collision between a semi-trailer and a V/Line p…
…ocedures contributed to the overall tragedy. Key preventable factors included: lack of proper pre-hospital triage protocols, over-triage leading to inappropriate air transfer of one victim without intensive care paramedi…
46y · Female·Ms Glendinning: multiple sharp force injuries (suicide); Jane Cuzens: multiple i…
…of prejudicing her custody case; her ability to appear rational when motivated; absence of a psychiatric assessment despite a Family Court judge requesting one in 2008; and lack of coordination in late 2011 when her ment…
48y · Male·Drowning
…s death. Despite expressing suicidal intent with specific plans on first presentation, he left after being triaged for mental health assessment. He re-presented within hours, was deemed not to meet Mental Health Act crit…
34y · Male·Haemopericardium due to dissecting thoracic aortic aneurysm
A 34-year-old man with a bicuspid aortic valve presented to ED twice on 5 September 2017 with chest pain. On both occasions, the ED was at full capacity ('Access Block'). He left without being seen both times, before a c…
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…
Male·Multiple: ligature compression of neck (hanging) in four cases; incised injury t…
…oring. Adverse childhood events and personality disorders were not adequately factored into suicide risk assessments. The coroner recommended urgent recruitment of PCS/mental health staff, increased ligature-minimised ce…
27y · Male·Neck compression due to self-inflicted hanging
…unsigned, incomplete Health Problem Notification Form (HPNF) dated 19 April that should have triggered reassessment but did not; failure to complete mandatory welfare check and mental health triage on initial reception; …
56y · Male·hypothermia
…He had a history of heavy alcohol consumption and was on antidepressants. The ED medical and psychiatric assessments were suboptimal; alcohol withdrawal was not adequately considered despite his trembling and neuropsychi…
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…
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. …
36y · Male·Toxic overdose of Clozapine (anti-psychotic drug), self-administered, with termi…
Brian Duff, a 36-year-old with severe chronic schizophrenia, died from Clozapine toxicity (pulmonary oedema and cardiac arrest) on 14-15 February 1997. He was subject to a Community Treatment Order and under case managem…
0y · Female·Unascertained
…h. The report documented overcrowding, poor hygiene, and aggressive parental behaviour. The 24-hour risk assessment was not completed; instead, the matter was deferred to a weekly allocation meeting scheduled for after J…
46y · Female·Multiple injuries sustained in collision between semi-trailer and train; tension…
…otocols—rather than single causes. Better brake inspection protocols, improved traffic counting for risk assessment, in-vehicle warning systems, and trauma triage protocols were identified as key preventative measures.
17y · Male·Diabetic ketoacidosis
Caleb Pearson, a 17-year-old with undiagnosed Type 1 diabetes, presented with pharyngitis and was diagnosed and treated for a throat infection by his GP on 25 May 2015. Over the following two days he deteriorated with vo…
38y · Male·stab wound to abdomen
…inal matter resulting in acquittal. However, it highlights the importance of emergency responders' rapid assessment of injuries incompatible with life, appropriate triage decisions, and the psychological and social impac…
0y · Female·Hypoxic-ischaemic encephalopathy arising from thrombosis in Blalock-Taussig shun…
…er presenting to hospital with vomiting and signs of dehydration. Clinical lessons: the delay in medical assessment (55-58 minutes for a triage category 3 patient with critical cardiac disease) was less than acceptable. …
Blunt force trauma sustained in level crossing collisions between heavy vehicles…
…medic support. Coroner identifies systematic failures in design standards, maintenance regulations, risk assessment protocols, and trauma triage procedures. Makes 25 recommendations addressing driver behavior research, v…
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