538 results for “observation”
37y · Male·hypoxic brain injury secondary to airway obstruction
…complete removal of plastic bags from the unit, enhanced documentation procedures, and randomisation of observation timing to reduce predictability.
0y · Male·Sudden Infant Death Syndrome (SIDS) against a background of sub-glottic stenosis…
…charge planning (Brisbane assumed direct home discharge, but Townsville expected hospital admission for observation); discharge planning for vulnerable neonates requires explicit consultant-to-consultant communication; …
50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…
…ession with suicidal ideation. The coroner found he should have been under continuous rather than close observations, and that key psychiatric warnings (paranoid comments, thought-disordered writings) were not adequatel…
29y · Male·acute bronchopneumonia complicated by multi-drug toxicity
…ism. Critical failures: RMO not consulting psychiatrist before prescribing medication; inadequate close observation procedures; staff lack of knowledge about drug interactions. The coroner recommended improved observati…
24y · Male·diffuse hypoxic ischaemic encephalopathy due to hanging
…to be at-risk—he was left alone for 40 minutes without checks, despite being flagged as requiring close observation after expressing suicidal ideation; (3) Inappropriate deployment of an Aboriginal Community Constable w…
98y · Male·comminuted pertrochanteric fracture of left hip sustained in mechanical fall
…was inadequate with no progress notes, falls assessment, or care plans provided; and the timing of last observation and overnight checks remained unclear. While the hospital's decision to palliate rather than surgically…
39y · Female·Hypoxic brain injury secondary to hanging
…ucted (only ad-hoc progress notes), failure to explore her stated suicide plan, undocumented changes to observation levels, and patient access to a dressing gown cord. Six days after admission, she hanged herself in an …
55y · Female·hypoxic brain injury complicated by aspiration pneumonia
A 55-year-old woman with chronic schizophrenia died from hypoxic brain injury after suffocating herself with a plastic bin liner while hospitalised in a rural hospital. She was admitted following a disturbance where she …
46y · Female·Hypoxic brain injury in the setting of plastic bag asphyxia
…he bag over her head. Critical failures included: insufficient staffing coverage led to a missed hourly observation at 12.00pm when two LDU nurses were assisting in the HDU; failure to perform a required formal risk ass…
31y · Male·ligature compression of the neck (hanging)
…). Despite psychiatrists identifying him as extremely high suicide risk and requesting one-to-one guard observation, a system failure resulted in inadequate supervision. During a Code Black emergency involving an adjace…
41y · Male·Septicaemia secondary to chronic peptic ulcer disease
Simon Cartwright, a 41-year-old man with schizophrenia and bipolar disorder, died in custody from septicemia secondary to chronic peptic ulcer disease. He had a documented ulcer history diagnosed in November 2020 and sho…
21y · Male·Cardiorespiratory arrest associated with butane abuse by inhalation
…out documented justification, and equivocal assurances about avoiding substances, insufficient enhanced observation was implemented. He obtained two butane canisters from a nearby store, likely using withdrawn cash. The…
60y · Female·neck compression by ligature strangulation
…ation, reported suicidal history, PTSD diagnosis, and assertion of recent overdose. Mandatory 15-minute observations and CCTV monitoring were inadequate. Her leggings were not removed despite being elastic and capable o…
23y · Male·hanging
…. Despite appropriate initial assessment by the admitting psychiatrist (Dr B.) and placement on Level 2 observations (15-minute checks), key systemic failures contributed to preventability: no medical handover occurred …
42y · Male·hanging
…ation; (2) cancelled psychiatric appointments were not reliably rescheduled; (3) rapid de-escalation of observation status in high-risk prisoners, despite explicit statements about concealing suicidal intent, may be uns…
62y · Male·Head injuries sustained in a fall from height
…cidal ideation in intercepted letters (December 2012 and March 2013) and was appropriately placed under observation and risk assessment by Justice Health on multiple occasions. Each time he denied current intent and was…
0y · Male·hypoxia and reduced pulmonary perfusion complicating congenital heart disease
…s and clinical uncertainty; (4) admission to PICU rather than Rose Ward would have been preferable; (5) observation charts lacked clear escalation protocols for modified saturation levels. The coroner found care decisio…
17y · Male·ligature compression of the neck (hanging)
…ric wards regardless of voluntary status; (2) documented risk assessments and medical authorisation for observation changes are essential; (3) after a reported serious suicide attempt, automatic escalation to secure psy…
41y · Female·Multiple injuries due to impact by train
…g; lack of awareness that the patient was returning to the ward (preventing preparation or higher-level observation); a staff member unlocking the door without recognizing her status, likely to allow a visitor to leave;…
28y · Male·Drowning
…npatients go missing, clear communication between mental health services, and consideration of enhanced observation levels for patients with acute symptom exacerbation.
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