149 results for “blood testing”
56y · Female·pulmonary thromboembolism due to left calf deep vein thrombosis
…surgery. On 13 July, an intern noted oxygen saturation of 95% on supplemental oxygen and obtained arterial blood gas tests showing hypoxia, raising concern for pulmonary embolism. However, the registrar was not informed…
82y · Female·Hyperkalaemia due to acute renal failure on a background of end stage pulmonary …
An 82-year-old woman with terminal pulmonary fibrosis and chronic respiratory failure presented with chest pain, hyperkalaemia and metabolic acidosis. She became combative and was given haloperidol and morphine for agita…
21y · Male·Sepsis caused by Leptospirosis (Graeme Gulliver); Group A streptococcal meningit…
…later. The third patient (82-year-old with E. coli septicaemia) was discharged on 19 July despite positive blood cultures not being actioned, then readmitted and died four days later. Common failures: inadequate doctor …
63y · Male·metastatic rectal carcinoma
…ay 2017 (ED assessment missed large rectal mass despite examination). Annual health reviews, faecal occult blood testing, and weight monitoring were not performed. Had colonoscopy been offered and accepted in 2015, tumo…
7y · Female·Multiple abdominal injuries including traumatic rupture of the liver and stomach…
A 7-year-old girl died from massive abdominal injuries sustained when a car, driven by an insulin-dependent diabetic man, collided with a group of pedestrians. The driver had undiagnosed and unaware hypoglycemia at the t…
11y · Male·Sepsis
…osseous or intramuscular administration, and communication breakdown (junior registrar unaware of critical blood gas results showing acidosis and elevated lactate). The coroner found this delay in treatment was not appr…
20y · Male·acute heat stress (circumstances undetermined)
Michael Campbell, aged 20 months, died on 18 April 2008 from acute heat stress. He was placed in his bedroom cot by his mother after returning home from grandparents' house. He was found unconscious and extremely hot app…
38y · Male·acute cardiac arrhythmia in a man with cardiomegaly, focal coronary atherosclero…
…d low oxygen saturations and high-risk cardiac status; a missed opportunity to perform pulmonary function testing during his April-May 2019 admission; failure to obtain physical observations on the evening of 7 June whe…
39y · Male·Strychnine toxicity
Randall Coleman, 39, died from strychnine toxicity after deliberately ingesting poison while in custody at Kingaroy watchhouse on 18 January 2007. He had secreted the vial on his person at arrest on 16 January, despite p…
72y · Male·Subarachnoid haemorrhage in a man with coronary arteriosclerosis
Ilija Kocovski, a 72-year-old man with a history of ischaemic heart disease, presented to Royal Perth Hospital Emergency Department on 22 October 2000 with chest pain, nausea, vomiting, and headache after arriving in Per…
6y · Female·Brain stem herniation due to pneumococcal meningitis
… referral letters highlighting key risk factors must be acted upon and communicated across care teams; (4) blood tests should have been ordered in ED despite clinical presentation suggesting viral illness; (5) critical …
22y · Male·Mixed Diflunisal and Buproprion (Zyban) toxicity
…onsciousness, and failure to recognise the multi-drug overdose despite positive paracetamol and salicylate blood tests. The patient's non-disclosure of diflunisal was a complicating factor, but inadequate questioning by…
28y · Female·3,4-methylenedioxy-N-methylamphetamine (MDMA) and ketamine toxicity
Trang Thi Thu Le, 28, died on her birthday from MDMA and ketamine toxicity after attending an electronic dance music event at John Cain Arena. She collapsed after consuming drugs purchased from an unknown source within t…
5y · Female·myocarditis
A five-year-old girl died from fulminant myocarditis caused by influenza A on 5 July 2022 at Canberra Hospital. The diagnosis was delayed over 7 hours from initial presentation. Critical failures included: ED triage Cate…
64y · Male·Complications of eosinophilic asthma with bronchiectasis and allergic bronchopul…
… and 20 October 2021. Toxicology revealed oxycodone and diazepam at levels that would be lethal in femoral blood, though splenic testing lacks reference ranges. These respiratory-depressant drugs were contraindicated gi…
81y · Female·Cardiac tamponade secondary to dissection of ascending aorta
An 81-year-old woman with hypertension and hypercholesterolaemia presented to the ED with sudden-onset central chest pain radiating to the jaw. Despite appropriate initial assessment and ruling out acute coronary syndrom…
33y · Male·Decompensated congestive cardiac failure complicating acute myocardial infarctio…
… on day 2 was an error in cardiogenic shock, and the decision should have been reviewed and cancelled when blood pressure fell critically. Advanced monitoring in ICU with inotropic support (dobutamine) and consideration…
19y · Male·neck compression due to hanging
…layground and hanged himself. Forensic autopsy confirmed hanging as cause of death with petrol detected in blood. No evidence of foul play. The coroner found clear suicide with warning signs observed in the community bu…
88y · Female·Sepsis complicated by multiple organ failure in a woman with comorbidities in th…
…ge to a low-care facility unable to provide needed medical support; failure to perform C-reactive protein testing or urine culture after catheter removal despite signs of delirium; and delayed recognition/escalation of …
Male·Angel Blanco-Puerto: acute heart failure as result of long-standing damage from …
…ccepted his explanation of bad fish and chips without hospital evaluation. Barry Gaykamangu had a systolic blood pressure of 70 (critically low) combined with elevated pulse suggesting shock, but officers did not recogn…
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