65y · Male·ischaemic and hypertensive heart disease with contributing acute cholecystitis (…
… and initially recovered well. On post-operative day 7, he experienced chest pain radiating to his jaw. Two ECGs were performed, both showing acute inferior myocardial infarction with ST elevation. The automated ECG int…
77y · Male·Complications of reaction to an iron infusion in a man with ischaemic heart dise…
…cing IV iron; (2) anaphylaxis requires immediate transfer to a monitored resuscitation area with continuous ECG monitoring, particularly in patients with cardiac disease; (3) specific informed consent for iron infusion …
37y · Male·cardiac arrhythmia
…scribed three antipsychotics when only two were intended due to failure to formally document cessation; (2) ECG monitoring should be performed baseline and regularly (every 6-12 months) for patients on QT-prolonging med…
45y · Male·focal coronary artery disease and cardiomegaly
…s prescribed multiple antipsychotic and sedative medications to manage his severe agitation and aggression. ECG monitoring revealed progressive QT interval prolongation, which can increase cardiac arrhythmia risk with c…
22y · Female·Sudden Arrhythmic Death Syndrome
…th syndrome due to long QT syndrome (LQTS). She presented multiple times to the Royal Women's Hospital with ECG changes and electrolyte abnormalities during pregnancy. Critical failures occurred in ECG interpretation an…
43y · Female·acute toxic effects of amitriptyline
…s admitted to Gold Coast University Hospital with suspected amitriptyline overdose. After 11 hours of ED monitoring, she was medically cleared and transferred to a mental health assessment pod, despite abnormal ECG findi…
37y · Male·Complications due to atherosclerotic heart disease and dyslipidaemia
… and dyslipidaemia while in custody at Darwin Correctional Centre. His death was avoidable. He had abnormal ECGs in 2019 and 2022 that were not appropriately escalated to cardiology. On 13 September 2022, an abnormal EC…
69y · Male·Myocardial infarction secondary to coronary artery atherosclerosis in the settin…
…topsy revealed acute myocardial infarction secondary to critical coronary artery atherosclerosis. A planned ECG was not performed due to patient restlessness. The coroner found no clinical fault with ED or GP management…
42y · Male·Cardiac arrhythmia secondary to electrolyte imbalance (hyperkalaemia) and verapa…
…ulfill what he misunderstood. (2) ED response – on second presentation with bradycardia, hyperkalaemia, and ECG changes suggesting life-threatening electrolyte disturbance, staff failed to recognise severity, didn't tri…
73y · Male·Consequences of myocardial infarction with coronary artery atherosclerotic disea…
…ure on 6 May 2013, six days after hip fracture surgery. He suffered a fall on 30 April 2013 following which ECG testing revealed cardiac abnormality. A first ECG at Sydney Hospital showed minor non-specific ST changes t…
19y · Female·combined drug effect and myocarditis
…ors. On admission to Graylands, the psychiatrist misread the dosage as 2.5mg and did not arrange cardiac monitoring despite haloperidol's QT-prolonging effects. Inadequate observations at Graylands failed to detect deter…
47y · Female·acute subendocardial septal myocardial infarction complicating hypertension and …
…s. The on-call doctor dismissed the presentation as psychogenic or reflux-related based on a normal initial ECG and lack of GTN response, despite classic cardiac symptoms and risk factors. He discharged her after sympto…
3y · Female·complications of Influenza B viral infection
…, she was triaged as Category 4 rather than higher acuity, experienced another seizure-like episode, but an ECG was not performed due to equipment battery failure. An ECG performed on the ward at 8:39pm showed widesprea…
84y · Female·Myocardial infarction
…ion following elective proctocolectomy. Post-operative care was deficient: chest pain on day 2 post-op with ECG showing atrial fibrillation and new right bundle-branch block was not investigated with troponin or blood t…
63y · Male·Hypoxic ischaemic brain injury and pneumonia complicating cardiac arrest in a ma…
…edications (diazepam, olanzapine, droperidol, promethazine, chlorpromazine). Critical failures included: no ECG or blood tests performed in ED despite high-risk medication exposure; lack of communication to psychiatric …
61y · Male·Undetermined
…rmined cause. Clinical lessons include: Eastern Health sedation guidelines were not followed; vital sign monitoring ceased at 7:45am on 4 April despite guidelines requiring observations for 72 hours; no ECG was performed…
60y · Female·haemopericardium following thoracic aortic dissection Type A
…d smoking history, presented to the ED with back pain, vomiting, incontinence, and sore throat. An abnormal ECG was obtained but not appropriately interpreted. She had minimal urine output over 7.5 hours despite cathete…
70y · Female·Heart failure due to paroxysmal atrial fibrillation treated with flecainide card…
…safer. Absent pharmacy cover meant no independent safety review of the unusual dosing and lack of protocol. ECG changes between infusions were not acted upon. Clinical lessons: recognise cognitive bias from prior succes…
76y · Male·Coronary atherosclerosis in the context of obesity, obstructive sleep apnoea, an…
… complications or severe sleep apnoea; (4) no planned ICU admission despite high risk profile; (5) abnormal ECG showing atrial fibrillation performed evening before death not communicated to treating physician; (6) ches…
29y · Female·Hypoxic Encephalopathy consequent upon Cardiorespiratory Arrest arising from eit…
…minutes before paramedics arrived. She died of hypoxic encephalopathy. Key clinical failures: inadequate monitoring (no ECG, no blood pressure recording during crisis), lack of intubation expertise in the attending clini…
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