35 results for “IV access”
1y · Female·pneumonia (staphylococcal pneumonia with bilateral bacterial pneumonia)
…rs contributed to her death, including failure to admit, delay in antibiotic administration, inadequate IV access, and poor preparation for transfer. The coroner referred Dr B. to the Medical Board of Western Australia.
58y · Male·chest and abdominal injuries sustained in motor vehicle collision
…one available due to policy restricting volunteers to first-aid level qualifications. Dr H. stated that IV access and fluid resuscitation packages could have saved the patient's life. The coroner identified a system fail…
0y · Unknown·sepsis leading to multiple organ failure syndrome
…ions were not recorded; paracetamol was given while waiting. The paediatric registrar could not achieve IV access at 3.00pm. A senior registrar was not called until 5.00pm, causing critical delays in diagnosis and treatm…
2y · Female·Complications relating to metastatic neuroblastoma
…liative hospice services. The coroner found medical care was of high standard and that earlier Dinutuximab access would likely not have altered the outcome given the aggressive disease course and poor response to immunot…
77y · Male·septic shock due to cellulitis of the left forearm
…er. Clinical lessons include the importance of early recognition of cellulitis signs, ensuring adequate IV access in patients with behavioural disturbance (including consideration of sedation or restraint), and prompt es…
71y · Male·metastatic caecal adenocarcinoma
…are directive was in place confirming he was not for resuscitation. His family was given increased bedside access in his final weeks. The coroner concluded that healthcare provided met expected standards and no act or om…
1y · Female·acute on chronic respiratory failure
…val unlikely even with optimal intervention. Clinical lessons include: inadequate training in intraosseous access for paediatric trauma when IV access fails; the need for direct communication between ambulance and ED sta…
39y · Male·Hypoxic/Ischaemic Encephalopathy due to Cerebral Arterial Gas Embolism
Phillip Ibrahim, a 39-year-old man recovering well from community-acquired pneumonia in ICU, suffered a fatal cerebral air embolism on 28 October 2014. A CVAD removal order was given at midday but the device remained in …
45y · Female·COVID pneumonia complicated by severe electrolyte abnormalities
…aemia, hypernatraemia, metabolic alkalosis) following influenza, then COVID-19 infection. Difficult venous access due to contractures prevented adequate IV access and PICC line insertion, limiting ability to monitor and …
21y · Male·Closed head injury and retroperitoneal and pelvic haematoma due to fractured pel…
…ransfusion, and detect clinical errors like the imperfectly positioned endotracheal tube; (2) Wide-bore IV access and early blood transfusion are critical in pelvic trauma—blood was unavailable until retrieval team arriv…
11y · Male·Sepsis
An 11-week-old premature infant presented to the ED with fever, lethargy and poor feeding. Despite initial suspicion of sepsis at 1:15pm, antibiotics were not administered until 4pm—a three-hour delay. Key failures inclu…
47y · Male·Drug toxicity in the setting of restraint
Robert Ferrier, aged 47, died from drug toxicity in the setting of restraint after ingesting excessive quantities of prescription antidepressants and other medications during a mental health crisis. The expert panel conc…
31y · Male·haemorrhage due to incised wound to left arm with amphetamine toxicity as a poss…
…ration to his left arm (cephalic vein injury). He was extremely combative, resisting oxygen therapy and IV access. Handcuffs were applied to the stretcher to enable safe transport and medical treatment. During ambulance …
46y · Female·Shock following interferon alpha treatment following removal of a melanoma
Lynette Young, 46, died of shock secondary to pericarditis with cardiac tamponade following interferon alpha treatment for melanoma. She presented with chest pain to Dubbo Base Hospital where multiple clinical failures o…
39y · Male·septicaemia following self-administered intravenous injection of faeces
… from a sharps container during escorted leave. Clinical lessons include: ensuring sharps containers are inaccessible to high-risk patients; maintaining adequate consultant psychiatrist review frequency (the coroner foun…
57y · Male·aspiration pneumonia secondary to small bowel obstruction
A 57-year-old man with chronic schizophrenia, intellectual disability, and history of bowel obstruction presented with faecal vomiting and signs of shock. He was appropriately transferred to hospital where small bowel ob…
1y · Female·Sepsis (Group A Streptococcus)
…review, critical delays occurred at the hospital: delayed recognition of septic shock, delayed intravenous access (three hours), delayed antibiotics and fluid resuscitation, and delayed retrieval initiation. The child de…
2y · Unknown·Hypoxic-ischaemic encephalopathy following sepsis related to abdominal surgical …
…g team; lack of documentation of specialist advice not to use the migrated tube; delayed recognition of IV access loss and hypoglycaemia; inadequate escalation to senior staff overnight despite MET calls; and ineffective…
90y · Female·Renal failure secondary to gentamicin therapy for urinary tract infection (sepsi…
… gentamicin in elderly patients with renal impairment, and ensure after-hours cover by plastic surgery has access to senior orthopaedic advice.
Toxicity from intravenous caesium, DMSO, and other substances administered as pa…
In May 2005, the Kathi Preston Memorial Health Centre (KPMHC) operated an unproven cancer therapy clinic from Dr B.'s home in Perth, Western Australia, administering intravenous treatment containing caesium, DMSO, and La…
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