185 results for “triage assessment”
66y · Male·Ruptured abdominal aortic aneurysm
…waiting over 6 hours in a crowded ED with restricted access to treatment spaces, he left without medical assessment, believing his symptoms were not severe. He returned to a regional hospital 8 hours later with worsening…
55y · Female·acute necrotising bronchopneumonia
…yspnoea, malaise and cough. She attended two telehealth GP appointments but did not receive face-to-face assessment or investigation despite colleagues expressing serious concern for serious cardiopulmonary pathology. Cr…
36y · Male·Heroin toxicity
A 36-year-old man with a history of homelessness and intravenous heroin use died from heroin toxicity after overdosing in a public toilet block. Emergency services were called promptly by a bystander who remained at the …
1y · Male·Cerebral anoxia caused by cardiac arrest caused by bronchiolitis and bronchopneu…
…st. The coroner found no evidence of pneumonia on 16 July examination and accepted that Dr M.'s clinical assessment met acceptable standards, though documentation of findings was inadequate. The coroner endorsed the view…
22y · Female·staphylococcal septicaemia and pneumonia complicating osteomyelitis of a right 1…
…nd inhumanely during her final hours, delaying ambulance transfer. Multiple systemic failures in medical assessment, police supervision, lock-up procedures, and cultural competency training were identified.
18y · Female·Colchicine toxicity
An 18-year-old female died from colchicine toxicity after intentional overdose of her father's medications during a mental health crisis. She ingested approximately 10-15g of colchicine (dose 0.25mg/kg), below the guidel…
23y · Male·Multiple injuries from being struck by train
… his partner being murdered to ED staff during bail service; and ED staff not requesting a mental health assessment despite clear indicators including recent self-harm, altered mental state, paranoid behaviour, and docum…
50y · Male·Stab wounds to chest and upper left limb
A 50-year-old man was stabbed to death by his partner's ex-partner, Mr F, in a premeditated attack at his home on 6 April 2015. The deceased and his partner had reported multiple threats and breaches of domestic violence…
55y · Male·Complications of liver cirrhosis and hepatocellular carcinoma in a man with mult…
…alliative care. The coroner noted improvements have since been made to prison medical continuity and nurse triage processes.
28y · Female·hypovolaemia due to spleen laceration due to blunt force trauma to the torso
Roberta Curry, 28, was killed by her former partner Lorenzo Deegan after repeated assaults, with a fatal blow causing splenic laceration. Critical failures included: police misclassifying her 000 calls as general disturb…
50y · Male·Multiple injuries sustained in collision between semi-trailer and train
A comprehensive coronial investigation into 26 deaths from 12 level crossing collisions in Victoria (2002-2009), with particular focus on the Kerang incident (5 June 2007) in which 11 train passengers died when a semi-tr…
30y · Male·traumatic brain injury
…itnesses knew he had hit his head heavily but ambulance operators were not informed, potentially affecting triage decisions; (2) incomplete handover of trauma information to hospital staff, who initially considered seizu…
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 received delayed diagnoses and treatment. The first patient (21-year-old with leptospirosis) pres…
22y · Male·Hypoxic ischaemic encephalopathy complicating hanging
…sappointing and inadequate, though could not definitively link them to his death. Key lessons: telephone assessment alone is insufficient for acute mental health crises; timely face-to-face review within 24 hours is esse…
36y · Male·Multiorgan failure complicating Streptococcus pyogenes septicaemia
Michael Nicoll, 36, presented to Cabrini Hospital ED with diarrhoea, vomiting, and dehydration. Dr P. diagnosed gastroenteritis and discharged him after IV fluids, despite dehydration, tachycardia, elevated creatinine, a…
52y · Male·Hanging
…h mental health services including a psychiatrist, psychologist specialising in OCD, and a hospital crisis triage service. While he denied suicidal ideation on formal assessment in May 2019, he expressed increasing suici…
23y · Female·chronic hydrocephalus with brain swelling
A 23-year-old registered nurse with undiagnosed chronic hydrocephalus presented to the ED with neck pain, headache and vomiting. Dr B. assessed her briefly without formal examination or detailed history, prescribed ketor…
13y · Male·Peritonitis secondary to ruptured gangrenous acute appendicitis
Luca Raso, a healthy 13-year-old boy, died from peritonitis secondary to ruptured gangrenous acute appendicitis after being misdiagnosed with viral gastroenteritis by his GP on two consultations (22 and 24 February 2017)…
34y · Female·Hanging with combined effects of ethanol and benzodiazepines
…e Gary Cox about 4 hours after arrival. Mr Cox did not conduct a formal mental state examination or risk assessment despite knowing of her recent attempted hanging, focusing instead on her requests for benzodiazepines. H…
70y · Male·Cyanide Toxicity
…ding from St Vincent's Hospital's Emergency Department. He had been placed on an involuntary psychiatric Assessment Order after expressing suicidal intent during custody assessment. In the ED, he was assessed as calm and…
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