332 results for “emergency patient transfer”
53y · Male·Cervical spine distraction and hanging
A 53-year-old man with chronic treatment-resistant depression and chronic suicidality was admitted to Northern Hospital following a serious suicide attempt. He was assessed as high-risk but discharged after 19 days with …
81y · Male·pneumonia
…e 2010 with shortness of breath and hypoxaemia. Dr F. provided prompt assessment and arranged appropriate transfer to the emergency department. Given his recurrent aspiration pneumonia secondary to post-stroke swallowing…
57y · Female·Complications of muscular dystrophy
…came acutely unwell overnight at her residential support facility with respiratory distress and required emergency transfer to hospital. Although paramedics did not transport her mechanical ventilators to hospital as pe…
47y · Male·Aspiration pneumonia due to or as a consequence of coronary atherosclerosis
…osclerosis following routine L5-S1 disc replacement. A critical oxygen desaturation (64%) occurred during transfer from theatre to PACU but was inadequately investigated—the anaesthetist assumed airway obstruction rather…
Unknown·Panella: pulmonary thromboembolism due to left calf deep vein thrombosis; Skeffi…
…en identified through blood tests before cardiac arrest. The Inquest examined systemic issues: inadequate patient visualisation at triage, lack of structured handovers, absence of deterioration protocols on ramps, insuf…
24y · Female·injuries sustained in descent from height
… in her mental health care or discharge planning. The main issues identified were: failure of information transfer between Eastern Health and other parties, the inappropriateness of family violence intervention orders fo…
69y · Male·bronchopneumonia and hypoxic brain injury following aspiration of food (choking)
…evisited and monitored during periods of concurrent illness or cognitive decline, particularly in elderly patients with dementia.
73y · Male·sepsis due to ischemic gut due to occlusion of the superior mesenteric artery
…ot identified until 4:45am—over 4 hours later—when surgical staff reviewed the scan. This delay meant the patient underwent exploratory laparotomy at Launceston General Hospital (LGH) rather than proceeding directly to …
48y · Female·Ischaemic bowel, with contributing conditions of coronary artery disease, diabet…
… Throughout her custody, she reported nausea, vomiting, inability to eat or drink, and requested hospital transfer on multiple occasions. Expert evidence confirmed inadequate care: she should have been screened at recept…
49y · Male·Carbon monoxide toxicity
…ssing him as low risk. The coroner found this discharge clinically reasonable and appropriate, noting the patient's willingness to engage with community care and his reassessment two days later showed continued improvem…
40y · Male·Cardiomyopathy with early pneumonia in a man with reported sleep apnoea and high…
…ber and could not be revived. Clinical lessons: undiagnosed cardiac disease and untreated sleep apnoea in patients requiring sedation pose serious risks; visual respiratory observations alone may not detect hypoventilat…
69y · Female·Asthma
…d Hospital. She deteriorated overnight in the hospital's Respiratory Ward despite initial improvement in Emergency Department. She was managed by an inexperienced junior doctor (intern, 5 months post-graduation) without…
38 and 3y · Female and male·Stacey: hanging; Seth: undetermined causes (likely suffocation, drowning, or str…
Stacey Docherty, a 38-year-old woman with complex post-traumatic stress disorder and borderline personality disorder resulting from childhood sexual abuse, killed her 3-year-old son Seth before taking her own life in Mar…
35y · Male·Acute Staphylococcus aureus Meningitis
…m-pit and prescribed antibiotics, which he declined. Subsequent presentations to Joondalup Health Campus Emergency Department on 27, 28-29, and 30 November 2002 were managed as soft tissue neck injury with normal CT and…
30y · Female·Multi organ failure from hydrochloric acid ingestion
…on of care across three different community mental health teams within three days, incomplete information transfer between services, absence of psychiatric assessment, and lack of coordination with her treating psycholog…
75y · Female·pyelonephritis and pneumonia
…nfection as a chest infection and prescribed only oral antibiotics when intravenous therapy was required. Transfer to hospital was delayed until 15 August, by which time she was critically ill. Expert evidence establishe…
86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall
…r 2024 sustaining rib fractures that caused a fatal left haemothorax. Paramedics attended but he declined transfer. When facial droop developed, he was admitted with presumed transient ischemic attack. Clinical fixation …
0y · Male·Complications of hypoxic ischaemic encephalopathy secondary to recurrent episode…
…uction, and the paramedic crew receiving an R3 (not R1) response code contributed to deterioration during transfer. Kyran sustained multiple cardiac arrests before arriving at Sydney Children's Hospital with hypoxic isch…
Blunt force trauma sustained in level crossing collisions between heavy vehicles…
…g distances (requiring 131+ metres); inadequate semi-trailer brake maintenance; and critical failures in emergency medical response including inappropriate fixed-wing aircraft transfer of trauma patient without Mobile I…
38y · Female·complications following a ruptured ectopic pregnancy
…m District Hospital with severe pain and was diagnosed with a possible ectopic pregnancy requiring urgent transfer to Goulburn Valley Hospital. Critical failures occurred in the ambulance transfer: the case was initially…
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