16 results for “CT scan (not performed but would have been diagnostic)”
76y · Male·ruptured abdominal aortic aneurysm
…onia/sepsis) based on elevated white cell count, C-reactive protein, and toxic granulation. No abdominal CT scan was performed. The coroner found it more probable than not that Mr Carter was experiencing a leaking AAA on…
94y · Female·Complications of metastatic lobular carcinoma of the breast in a woman with deme…
… her malignancy. She presented repeatedly with vomiting due to duodenal obstruction from metastatic tumour, but this was not diagnosed until 15 November 2017, two weeks into her final admission. A critical error occurre…
89y · Male·fractured cervical spine (C5 inferior articular process fracture) due to unwitne…
…nt disruption and spinal cord compression, converting the injury to a C5-C6 paraplegia/quadriplegia. An MRI scan would have detected the ligamentous injury and prevented mobilisation. The patient underwent delayed neuros…
59y · Male·ischaemic heart disease in the context of acute-on-chronic kidney failure associ…
… a 59-year-old prisoner with advanced cardiac disease, chronic kidney disease, and diabetes, underwent a CT scan with iodinated contrast on 30 July 2015 at Fiona Stanley Hospital. Critical failures occurred: his kidney f…
18y · Male·complications of acute on chronic subdural haemorrhage (operated) in the setting…
…018, presenting with headache, nausea and dizziness. Dr H. reviewed him on 31 October with ongoing symptoms but did not order a CT scan, which the coroner found would have been prudent. George presented to Frankston ED …
75y · Male·acute right subdural haemorrhage sustained in a fall
…then falling onto concrete at a shopping centre on 15 August 2014. Both times he was assessed by GPs who performed neurological examinations, found GCS 15, and discharged him home with observation instructions. Neither …
45y · Male·intracerebral haemorrhage caused by rupture of arterial aneurysm
…d flags. He died from fatal rebleeding 6 weeks later. The death was preventable with timely imaging; had CT scanning been performed on first or second presentation, the aneurysm would likely have been identified with goo…
63y · Male·Cerebral infarction complicating vertebral artery dissection following motor veh…
…ion. At Albury Base Hospital, initial CT imaging at 10:44am identified significant cervical spine injuries, but critical imaging results (MRI and CT angiogram) were delayed approximately 4.5 hours. The patient deteriora…
77y · Female·Haemoperitoneum following cholecystectomy
…c cholecystectomy. Bleeding from the left inferior epigastric artery was a recognised surgical complication but was not identified until 12:14 pm on day 3, despite clinical signs from 9:30 am. Key failures included: del…
40y · Female·Cerebral oedema of unknown aetiology with probable contribution from Hashimoto's…
Sarah Louise Rose, aged 40, died from cerebral oedema of unknown aetiology with probable contribution from Hashimoto's encephalopathy. She had been diagnosed with Hashimoto's thyroiditis in late 2011 and pr…
39y · Male·pneumococcal meningitis with severe cerebral oedema due to pneumococcal mastoidi…
… ENT infection. Over 15 days, he developed pneumococcal meningitis with severe cerebral oedema—a recognised but uncommon complication of ear infection. Meningitis was suspected on admission but never definitively invest…
54y · Male·Bowel ischaemia resulting from acute thrombosis of superior mesenteric artery an…
…al knee replacement surgery at Fairfield Hospital on 28 September 2018. A vascular surgeon consultation had been explicitly requested by his orthopaedic surgeon but was not identified and actioned by any of the clinical …
54y · Male·Global cerebral hypoxic injury due to or as a consequence of status epilepticus
Terence James Robinson, 54, died from status epilepticus causing global cerebral hypoxic injury after 16 days at Belmont Private Hospital. He was admitted following a violent altercation with police and attempted suicide…
72y · Male·acute gangrene of colon with probable perforation along with bowel obstruction a…
…tal on Christmas Day 2002 with acute abdominal pain and vomiting. Over two days, his condition deteriorated but ischaemic bowel disease was not diagnosed until the afternoon of 27 December, by which time it was too late…
65y · Male·staphylococcal sepsis (secondary to Staphylococcus aureus infection seeding rect…
…en contaminated farm soil abrasions to his elbow and knee. Junior surgical staff noted the abnormal results but did not escalate them to the consultant surgeon, Mr Kamenjarin, who did not proactively interrogate patholo…
64y · Female·Bilateral pulmonary embolism with left middle cerebral artery/posterior cerebral…
…ion breakdown and transport resource constraints. Earlier recognition of complexity and expedited transfer would have significantly enhanced her prospects.
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