185 results for “triage assessment”
28y · Male·Acute Dopamine Imbalance Syndrome
…the ED where he spent five hours undergoing vague "physical clearance" rather than targeted neurological assessment despite known abnormal EEG and recent antipsychotic initiation. His Glasgow coma score collapsed from 13…
60y · Male·medication overdose
Bruce Andrews, a 60-year-old man with major depression and anxiety, died from medication overdose following relationship breakdown and acute alcohol intoxication. He fell from his porch, called his granddaughter reportin…
17y · Male·Suicide by self-inflicted hanging
…gnizing high risk; questionable discharge decision on 2 November 2023 (four days before death) regarding assessment of depression severity, with concerns that adult assessment criteria were applied rather than adolescent…
16y · Female·consequences of acute asthma with hypoxic encephalopathy
… testing (spirometry or peak flow) was performed despite this being essential for diagnosis and severity assessment; (3) asthma severity was underestimated—by 3 May, Jessica-Lee had moderate-to-severe asthma requiring ho…
23y · Male·Hypoxic-ischaemic encephalopathy due to hanging
…ure to share information on clinical grounds. Resource constraints caused a significant delay in medical assessment. The response by QCS staff to the hanging incident was immediate and appropriate. No evidence suggests p…
48y · Male·undetermined
…nsidering respiratory sensitivity is essential; coordination between services (local hospital, psychiatric triage, retrieval services) requires defined leadership and protocols.
32y · Male·Head and neck trauma (train impact)
Travis Hartskeerl, a 32-year-old man with a complex history of schizophrenia, polysubstance abuse, and multiple serious suicide attempts, died by suicide on railway tracks on 16 December 2008. He had been discharged from…
39y · Male·Cardiac arrhythmia following violent exertion necessitating physical restraint i…
…ne, exhibiting drug-induced psychosis with agitation and paranoid thoughts. After leaving the ED without assessment, police encountered him at Officeworks. He made threats to kill officers, lunged at them, and attempted …
28y · Female·acute streptococcus pneumonia meningitis with left-sided otitis media as anteced…
Michelle McIlquham, 28 years old, died from undiagnosed acute bacterial meningitis (streptococcus pneumonia) that developed from a middle ear infection. She presented to Bankstown Hospital Emergency Department with a fir…
76y · Male·small bowel obstruction in the setting of terminal metastatic neuro-endocrine tu…
A 76-year-old Aboriginal man died of small bowel obstruction from metastatic neuro-endocrine tumour after spending nearly two years requesting medical help in prison without receiving a doctor's review. Between October 2…
43y · Female·acute toxic effects of amitriptyline
… overdose. After 11 hours of ED monitoring, she was medically cleared and transferred to a mental health assessment pod, despite abnormal ECG findings with T-wave changes not fully investigated (troponin test ordered but…
44y · Male·Hanging
…Correctional Centre on 13 November 2015. He was on hourly observations for suicide risk following a Risk Assessment Team meeting that determined he should remain in unit S3. However, a Sentence Management officer conduct…
5y · Female·myocarditis
…Hospital. The diagnosis was delayed over 7 hours from initial presentation. Critical failures included: ED triage Category 3 assignment but no medical review for 5 hours (required within 30 minutes); misinterpretation of…
54y · Male·Pneumonia due to Staphylococcus aureus
…tics, but was never seen by a doctor. Key clinical concerns include: inadequate documentation of nursing assessments; two nurses auscultated his chest on day 3 with conflicting findings (crackles vs clear), but this was …
16y · Male·Peritonitis as a result of ruptured duodenum following blunt trauma of the torso
A 16-year-old boy died from peritonitis secondary to duodenal rupture two days after being treated and discharged from Campbelltown Hospital Emergency Department for a rugby injury. He sustained blunt abdominal trauma fr…
24y · Male·Haemorrhagic shock in the setting of a sharp force injury to the left arm
…rehension under the Mental Health Act for erratic, aggressive behaviour. Each time, ED and mental health assessments determined he did not meet criteria for compulsory treatment. The coroner found clinical care was reaso…
69y · Female·faecal peritonitis due to small bowel obstruction and perforation due to periton…
A 69-year-old woman presented to the Emergency Department with abdominal pain and vomiting. The doctor did not take adequate history, perform thorough physical examination, or order basic investigations including blood t…
26y · Female·Complications of liposuction surgery: sepsis, decreased respiratory function sec…
…ication between practitioners. The post-operative care protocol at the clinic, which interposed Dr C. as a triage contact, created confusion about responsibility. Injectable pethidine was administered without adequate ob…
6y · Male·pneumonia complicating influenza A (H1N1) infection with secondary streptococcal…
Sebastian Parman, a 6-year-old boy, died from pneumonia complicating influenza H1N1 with secondary group A streptococcal infection causing scarlet fever, empyema and sepsis. Multiple clinical failures contributed: an inf…
42y · Female·Hypoxic ischemic encephalopathy with antecedent cause being self-caused near mis…
…between agencies; the Mental Health ACT failure to notify the Court Liaison Officer; lack of psychiatric assessment before transport despite clear warning signs; and the use of an unsuitable transport vehicle without sur…
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