185 results for “triage assessment”
43y · Male·exsanguination from incised wounds to the arms - self inflicted
…unity team was limited to two brief phone calls for appointment arrangement purposes, without documented assessment of suicidal ideation, psychotic symptoms, or illicit drug use—all high-risk factors. When he missed a sc…
26y · Male·Multiple injuries from collision between semi-trailer and train at level crossin…
…oorly conspicuous for truck drivers; LEDs had been recommended but not upgraded pre-collision), the risk assessment model's failures, and emergency response issues. The investigation emphasises that level crossing safety…
27y · Female·Septicaemia secondary to Neisseria meningitides infection
…/50mmHg), she was discharged after 34 minutes with only paracetamol, without medical review, proper pain assessment, or fetal examination. Prior to this, she had made 18+ presentations over 7 months with vomiting, abdomi…
35y · Female·Pulmonary thromboembolus and pulmonary infarction
…ollapse with massive bilateral pulmonary emboli and died despite thrombectomy. The coroner found Dr M.'s assessment insufficiently thorough—PE should have been more actively excluded through basic investigations (ECG, ch…
41y · Female·ligature compression of the neck (hanging)
…ties for enhanced care. The coroner made recommendations regarding ligature remediation funding, access to triage documentation during assessments, and nurse-patient allocation ratios.
32y · Male·Multiple injuries sustained when struck by semi-trailer at level crossing
…ic support. The investigation identified systemic failures in level crossing infrastructure design, risk assessment processes, vehicle maintenance standards, and emergency coordination that contributed to the outcome.
43y · Male·Hanging
… denial of psychiatric and medical review despite five explicit requests for medication adjustment. GS was triaged as non-urgent (category 3) and remained on waitlists without assessment by any medical practitioner. Expe…
44y · Female·Hanging
…able electronic records; her self-referral form requesting urgent mental health medication was incorrectly triaged as non-urgent despite clear signs of mental health deterioration; and her verbal requests for medical ass…
17y · Male·intra-abdominal haemorrhage complicating partial pancreatectomy for traumatic pa…
…. Pain recurred on 22 May morning with reports of being cold and clammy (suggesting shock), but clinical assessment by on-call registrar unfamiliar with the case resulted in recommendation to wait at home. Critical failu…
Multiple penetrating knife wounds with hemorrhagic shock and traumatic cardiac a…
…he 'hot zone' designation. Recommendations addressed: schizophrenia management guidelines, mental health assessment for weapons licensing, emergency services interoperability, and media reporting guidelines for mass casu…
8y · Male·bacterial meningitis that had not been diagnosed by a number of clinicians who h…
Eight-year-old Isaraelu Pele died of bacterial meningitis missed by multiple clinicians despite three hospital presentations and two GP visits between 14–17 December 2007. Critical failures included: inadequate different…
8y · Female·Multiple injuries sustained in collision between semi-trailer and train at level…
…ning conspicuity for heavy vehicle drivers, inadequate heavy vehicle maintenance standards, and suboptimal triage and transport decisions in the emergency response that may have contributed to one preventable death.
71y · Male·Multiple injuries sustained in a cycling accident caused by impact with a tree b…
…sed promptly. The coroner found a public safety issue arising from systemic failures in how the government triaged and responded to hazard reports. Had the report been correctly routed to the arborist team, the hazard wo…
41y · Female·neck compression
…ve despite high-risk status; he absconded and met with Lynch. The AWOL procedure had gaps: the Psychiatric Triage Service wasn't notified, nominated contacts weren't contacted within 30 minutes, and the missing person in…
22y · Male·Blunt head injury occasioned when the deceased fell from a moving vehicle
…essons include: severe head injury with Glasgow Coma Score 3 requires immediate specialist neurosurgical assessment; early communication about apparent neurological improvement can misleadingly lower clinical urgency; an…
47y · Female·insulin overdose
…23 April, she was assessed at Wonthaggi Hospital for suspected overdose and given a deferred psychiatric assessment. She discharged herself early the next morning, visited her workplace and solicitor, then checked into a…
48y · Male·unascertained
Daniel Harvey, a 48-year-old man with morbid obesity, cirrhosis, diabetes, and polysubstance use including methadone and methamphetamine, was found unresponsive in immigration detention on 10 August 2020. He had complain…
37y · Male·Complications due to atherosclerotic heart disease and dyslipidaemia
… non-clinical and clinical staff must be direct and complete; high-risk patients require full vital sign assessment; deteriorating prisoners need urgent escalation and close monitoring.
Unknown·Ruby Nicholls-Diver: ligature compression of neck (hanging); Carly Jean Elliott:…
…uate risk management and discharge planning, poor communication with families, lack of longitudinal risk assessment procedures, and insufficient follow-up. Clinicians failed to contact next-of-kin about discharge despite…
53y · Female·cardiorespiratory arrest in a person with blunt force head injury, end-stage liv…
…ho noted slurred speech attributed to her baseline condition, found her oriented and capable of refusing assessment, and allowed her to leave. She discharged herself against medical advice without documented injury asses…
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