161 results for “clinical dehydration”
79y · Female·Chronic obstructive pulmonary disease
…ad severe COPD and was frail (29kg). On 10 April 2017, when she deteriorated with respiratory distress, a Clinical Nurse Consultant (CNC) and the treating GP agreed to commence morphine and midazolam without the GP condu…
0y · Male·Complications of hypoxic ischaemic encephalopathy secondary to recurrent episode…
…iagnosed with gastroenteritis based on recent rotavirus vaccination and absent diarrhoea, despite several clinical red flags. Critical failures occurred overnight: nursing staff did not escalate concerns about continued …
65y · Female·heatstroke
…nduct public inquiries about her movements or seek community sightings despite the unusual circumstances. Clinical lessons include: recognising cognitive decline as a risk factor for adverse outcomes; ensuring vulnerable…
11y · Female·Sepsis due to acute peritonitis secondary to perforated gangrenous acute appendi…
…btain prompt medical assessment for a sick child with persisting symptoms was the key preventable factor. Clinical lessons include: non-specific appendicitis presentations in children can mimic gastroenteritis; caregiver…
23y · Female·Unascertained
…d have survived. The coroner examined whether the ambulance paramedics' decision not to transport her was clinically inappropriate. The coroner found the paramedics' assessment complied with clinical guidelines; vital si…
29y · Male·Florid myocarditis
…multiple episodes of syncope including collapse in the waiting room. Dr P. diagnosed viral illness with dehydration and discharged him with advice to take fluids and ibuprofen. Autopsy revealed severe myocarditis with p…
45y · Male·Complications of heat stroke in a man with schizophrenia
Christopher Dokos, a 45-year-old man with schizophrenia on Clozapine treatment, died during the extraordinary January 2014 Victorian heatwave. He had multiple heat-vulnerability risk factors: mental illness, antipsychoti…
41y · Male·Pheniramine toxicity
…on, disorientation, unsteady gait—was incorrectly attributed to mental illness rather than drug toxicity. Clinical lessons include: the diagnostic difficulty in distinguishing drug toxicity from psychiatric illness or in…
46y · Female·pulmonary thromboembolism due to bilateral deep calf vein thrombosis
…d tachycardia on day 2-3 of admission were not vigorously investigated for sepsis or other complications. Clinical lessons include: pursuing comprehensive physical assessment despite patient resistance; investigating une…
68y · Female·Complications of a fall with contributing factors of respiratory failure, respir…
Irene Charlish, a 68-year-old woman with longstanding schizoaffective disorder and multiple comorbidities, fell at her residential facility on 6 June 2017, sustaining a pneumothorax and rib fracture. She was admitted to …
63y · Male·cerebral infarction
… to death. Key lessons: inappropriate use of antipsychotics as sedatives in dementia, failure to escalate clinical deterioration promptly, and inadequate understanding of behavioural manifestations of frontotemporal deme…
50y · Female·Complications of heat stroke in a woman with schizophrenia
…ould have been appropriate and feasible safeguards. While the prescribing and monitoring of clozapine met clinical guidelines, the failure to actively manage identified high-risk patients during an extreme weather event …
27y · Male·Unknown
…y in extreme heat) or foul play by travelling companions (though no forensic evidence supports this). Key clinical relevance: the case highlights risks of drug and alcohol intoxication in remote settings, inadequate comm…
85y · Female·ischaemic heart disease due to stenosis of coronary bypass grafts
An 85-year-old woman with significant cardiac history (prior coronary artery bypass graft) presented with gastrointestinal symptoms. Her GP ceased rosuvastatin without direct communication to nursing staff. Care staff id…
70y · Male·gastrointestinal haemorrhage in a man with gastric ulcers
…lure to recognise disproportionate urea elevation, inadequate consultation with senior colleagues despite clinical uncertainty, and lack of discharge summary. The case illustrates the importance of pattern recognition, a…
89y · Female·Aspiration pneumonia complicating electroconvulsive therapy for treatment of psy…
…was appropriate given her deteriorating mental state and life-threatening refusal of intake. However, two clinical shortcomings were identified: (1) no second psychiatrist opinion was documented despite guidelines recomm…
52y · Female·Neutropenic sepsis leading to multi-organ failure due to capecitabine toxicity
…ith administration delayed until 29 October (3.5 days after drug cessation; ideally within 96 hours). Key clinical lessons include: recognising early capecitabine toxicity signs, lack of pre-treatment DPD enzyme deficien…
73y · Male·Acute subdural haematoma
Kerry James Murphy, 73, died from acute subdural haematoma following a fall in Royal Darwin Hospital's overcrowded Emergency Department. He was admitted with pneumonia, NSTEMI, and dizziness—significant fall risk factors…
27y · Male·acute myeloid leukaemia
…were remarkably near-normal despite extensive bone marrow involvement found at autopsy. The coroner found clinical management adequate and appropriate, though noting missed opportunities: the HPNF (Health Problem Notific…
16y · Male·Heat related illness in an individual with enterovirus D68 infection
…ld recognition of heat illness and initial cooling measures, he deteriorated rapidly and died in transit. Clinical lessons: heat-related illness was preventable through activity modification in extreme temperatures, bett…
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