125 results for “chronic severe pain”
39y · Male·Coronary thrombosis caused by coronary atherosclerosis
Lenard Casey, a 39-year-old Aboriginal man with severe coronary artery disease, died of acute coronary thrombosis while in custody. Arrested for assault on his p…
34y · Female·Combined drug toxicity (propofol, sevoflurane and others)
…cked theatre trolleys and administered to herself at home. She had a long history of depression, anxiety, chronic migraines, insomnia and prior self-harm. The anaesthetic agents likely provided temporary relief from her…
66y · Female·aspiration pneumonitis and gangrenous necrosis of both feet
A 66-year-old woman with untreated rheumatoid arthritis, severe lower limb cellulitis with gangrenous necrosis, and a personality disorder died from aspiration pneumoniti…
62y · Male·Multi-organ infarctions (brain, kidneys, heart) resulting from thromboemboli sec…
…h suspicion for this devastating complication, ensuring prompt diagnostic evaluation of post-ablation chest pain, and maintaining accurate contemporaneous records. While informed consent discussions occurred, written inf…
Female·bilateral acute bronchopneumonia
…y sustained from a hanging attempt in March 2000. The coroner found the death resulted inevitably from her severe irreversible brain injury. Medical teams correctly determined that invasive interventions for recurrent as…
84y · Female·Complications associated with Diabetes Mellitus (likely hyperosmolar hyperglycae…
…icit prescribing guidance is essential in aged care; (3) no assessment documented that Mrs Paluszak was in severe pain; (4) better communication between GP and nursing staff on starting doses is crucial. The GP did not p…
35y · Male·Hanging
…ature of his presentation. The deceased appears to have experienced some jaw discomfort but not documented severe pain proximate to death.
58y · Male·complications of large bowel pseudo-obstruction
…lowing discharge from hospital after inadequate assessment. He had presented to the ED with lower abdominal pain and severe faecal loading (bowel dilation 19cm). Despite a critical admission one year prior requiring ICU …
58y · Male·Hypertensive and valvular heart disease
…. He had complex pre-existing cardiac disease including previous valve replacement and aortic surgery with severe left ventricular hypertrophy. The coroner found his medical management in prison was appropriate and comme…
44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…
…changes; poor diabetes management including missed optometry and podiatry referrals; and failure to address painful ingrown toenails despite multiple requests. These failures were driven by severe under-resourcing: one G…
11y · Female·Complications of E. coli sepsis in association with intestinal obstruction due t…
Child R, an 11-year-old Aboriginal girl with congenital anorectal anomalies causing chronic severe constipation, presented to Halls Creek Hospital on 5 January 2017 with severe abdominal pain and v…
24y · Male·cardio-respiratory arrest due to multi-drug toxicity
Hugh Lisle, a 24-year-old man with severe chronic arthritis, depression, polysubstance addiction and gambling disorder, died in a private psychiatri…
51y · Male·Multiorgan failure in a man with corrected congenital coarctation of the aorta a…
…ion of aorta, valvular disease, and biventricular heart failure, presented to Alfred Hospital ED with chest pain and dyspnoea. He was diagnosed with NSTEMI and admitted. During preparation for cardiac catheterisation, he…
67y · Female·Pneumonia (streptococcus pneumoniae) in a woman receiving treatment for carcinom…
…ssion, nursing and medical staff disbelieved them. No investigations were performed for acute illness. Her severe pain from pneumonia was treated symptomatically. Dr L. admitted her to palliative care without urgent revi…
41y · Male·Subdural haematoma
…re attributed to cluster migraine, then alcohol withdrawal syndrome, despite concerning features including severe headache (9/10), vomiting, pupil changes, and progressive drowsiness. A subdural haemorrhage (acute on chr…
76y · Female·multiple organ failure due to abdominal wall cellulitis (surgically treated)
…ated significantly over 3 weeks with inadequate escalation and analgesia. By 23 August 2023, the wound was severely infected and malodourous with Mrs Crowther in severe pain—a critical moment when hospital referral shoul…
Bearham: hypoxic brain injury from hanging; Fisher: asphyxiation from hanging by…
Four inpatient suicides occurred at The Canberra Hospital mental health units between January 2015 and November 2016: three by hanging and one by jumping. The coroner found systemic failures including inadequate ligature…
51y · Female·Multiple injuries sustained from a fall from the top floor of a multi-storey car…
Justine Painter, aged 51, died from multiple injuries sustained jumping from a multi-storey carpark while an inpatient a…
46y · Female·Complications following cardiorespiratory arrest in association with an air embo…
… to read nursing notes documenting signs of sepsis (green bile drainage, elevated vital signs, shoulder tip pain), instead documenting her as 'stable'. On 12 November, critical observations showing respiratory distress (…
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…
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