332 results for “emergency patient transfer”
38y · Female·Asphyxiation by plastic bag
…owing a suicide attempt. The coroner found no criminal culpability. Key clinical lessons: the decision to transfer her from intensive psychiatric care to the ward was based on reasonable professional judgment at the time…
39y · Male·septicaemia following self-administered intravenous injection of faeces
…ndence died from septicaemia after self-injecting faeces into his vein while an involuntary mental health patient. He obtained a syringe from a sharps container during escorted leave. Clinical lessons include: ensuring …
31y · Male·Hypoxic encephalopathy caused by neck compression due to hanging
…owing hanging in a prison mental health unit. Despite being psychotic and refusing medication, he was not transferred to a specialised mental health facility (MHSU at Silverwater) for three weeks after his treating psych…
0y · Male·multi-organ failure from septicaemia following surgical reduction of intussuscep…
…t, relying instead on nursing staff verbal updates. The child deteriorated dramatically overnight and was transferred to Canberra Hospital on 15 October morning where intussusception was diagnosed and surgically reduced,…
28y · Female·Multiple injuries sustained in a fall from height
…died from multiple injuries sustained falling from an overpass after absconding from Sunshine Hospital's emergency department. She was released from custody on an Inpatient Assessment Order (IAO) and should have been tr…
73y · Male·Acute subdural haematoma
…s 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—yet no f…
42y · Female·pneumonia with diffuse alveolar damage in the setting of mixed drug toxicity (Ba…
…toxicity) whilst in seclusion in a mental health unit. Critical clinical failures included: inappropriate transfer from ICU to a mental health ward without adequate consultant-to-consultant discussion; inadequate physica…
74y · Male·cardiac arrhythmia in an elderly man with chronic obstructive pulmonary disease …
…on while imprisoned at Acacia Prison. He had received appropriate medical management initially, but after transfer to Acacia in April 2022, experienced disrupted follow-up care including missed medical appointments in Ju…
37y · Male·Pulmonary thromboembolus due to left leg deep vein thrombosis
…ed on suspected infective endocarditis, which was appropriately ruled out. However, the coroner found the patient had pulmonary embolism with classic clinical features that should have been investigated. Critical omissi…
59y · Male·multiorgan failure complicating paracetamol toxicity
…ry, when experiencing severe chest pain, did he reveal the overdose. Police responded promptly and he was transferred to Dandenong Hospital where he developed acute liver failure and multi-organ failure despite maximal i…
17y · Female·Multiple injuries sustained in collision between semi-trailer and train
…picuity for truck drivers), deficient heavy vehicle brake maintenance (unroadworthy trailer brakes), and emergency response issues including inappropriate air transport of a trauma patient. While some deaths were immedi…
77y · Male·Complications of reaction to an iron infusion in a man with ischaemic heart dise…
…or the cause of anaemia should be completed before commencing IV iron; (2) anaphylaxis requires immediate transfer to a monitored resuscitation area with continuous ECG monitoring, particularly in patients with cardiac d…
5y · Female·Multiple injuries sustained in a collision between a semi-trailer and a V/Line p…
…miliar drivers who aren't expecting trains. Poor maintenance of the semi-trailer's brakes and inadequate emergency response procedures contributed to the overall tragedy. Key preventable factors included: lack of proper…
77y · Female·combined effects of ischaemic heart disease and calcific aortic valve sclerosis
…ital, her ECG was abnormal but a cardiology registrar advised deferring troponin testing and arranging outpatient echocardiogram rather than urgent transfer to Royal Hobart Hospital's cardiac unit. She was discharged, c…
37y · Female·complications of withdrawal from chronic opiate use and Wilkie Syndrome in the s…
… or documentation. Veronica vomited persistently from withdrawal and other medical conditions but was not transferred to hospital despite clinical concern from nursing staff. She was transferred to mainstream prison on 1…
24y · Male·Hypoxic-ischaemic encephalopathy, due to or as a consequence of cardiac arrest, …
…riate antibiotics at the Manus Island clinic; failure to intubate and aggressively resuscitate him before transfer; inadequate handovers and communication between clinical teams; delayed transfer approval due to bureaucr…
21y · Male·Sepsis caused by Leptospirosis (Graeme Gulliver); Group A streptococcal meningit…
Three young patients died from severe bacterial infections at rural Queensland hospitals (Mossman and Atherton). All three re…
25y · Male·Multiple organ failure due to acute paracetamol poisoning
…isation. By 7 November Danny had a Glasgow Coma Scale of 11 indicating serious deterioration, yet was not transferred to hospital until afternoon despite clear clinical indicators warranting immediate evacuation. Paracet…
68y · Male·Complications following colon surgery on a background of cirrhosis of the liver;…
…ess saline given when sodium restriction was needed); gastroenterological input was not sought early; and transfer to specialist care should have occurred earlier when complications became apparent. An anastomotic leak r…
37y · Male·Respiratory arrest in association with medication drug effect and alcohol intoxi…
…ly aggressive. The coroner found the sustained deep sedation was inappropriate; optimal sedation for such patients should maintain rousability. When the patient removed his mask at 1:50am and subsequently received furth…
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