19 results for “arterial ultrasound”
68y · Female·Haemorrhage secondary to right subclavian artery lacerations sustained during ce…
…bclavian artery during central venous line insertion. The anaesthetist used anatomical landmarks without ultrasound after an initial high approach failed. Upon recognising arterial puncture, appropriate escalation occurr…
74y · Female·Complications of carotid artery injury from central line insertion in the settin…
…tershed ischaemia despite surgical repair. She subsequently developed multi-organ failure and died. While arterial puncture is a recognised 6-9% complication of CVC insertion, ultrasound guidance—now considered gold stan…
51y · Female·Pulmonary thromboembolism in the setting of morbid obesity
…bolism while an involuntary psychiatric inpatient. She presented with leg pain and swelling in May 2014; ultrasound was technically difficult due to body habitus and didn't identify DVT, though she was advised to pursue …
81y · Female·left haemothorax and mediastinal haemorrhage from the insertion site of the perm…
…in insertion. Implementation of cardiac-specific observation scoring systems, amended clinical pathways, ultrasound-guided vein puncture protocols, and clearer after-hours access procedures have since been instituted.
51y · Male·Sepsis due to or as a consequence of right lower limb necrotising fasciitis due …
…e and act on post-procedure bleeding complications—a competent cardiologist should have performed urgent ultrasound imaging on 11 May to exclude pseudo-aneurysm, which could have been treated with thrombin injection; (3)…
58y · Male·Ischaemic and hypertensive heart disease
John Christopher Mayger, aged 58, died of ischaemic and hypertensive heart disease while in custody at Adelaide Pre-release Centre. He had a significant cardiac history including two previous myocardial infarctions with …
31y · Male·Pulmonary thromboembolism arising from deep vein thrombosis
…/calf pain after flying. Despite risk factors (obesity, long-haul travel), DVT was not investigated with ultrasound. When he presented five days later with resolved leg pain, ultrasound was not pursued despite discussion…
63y · Male·Right cerebral infarction caused by infusion of medication via central venous li…
…ein. Although this was recognised 36 hours later, medications including dextrose had been infused via the arterial line, causing right cerebral infarction. The clinician relied on absence of pulsatile flow and blood colo…
59y · Female·complications of intra-abdominal sepsis, including multi-organ failure and bowel…
…tion and operation (affecting bile duct inflammation and infection risk); post-operative complications of arterial bleeding requiring re-operation; bile leak from anastomoses; conservative management of intra-abdominal c…
60y · Male·haemopericardium due to rupture of right ventricle complicating removal of cardi…
…y while an unproductive pulmonary angiogram was performed instead. The coroner found that had diagnostic ultrasound been immediately available, the haemopericardium diagnosis would have been made promptly, allowing earli…
45y · Male·Liver failure due to metastatic hepatocellular carcinoma
A 45-year-old male prisoner died from liver failure due to metastatic hepatocellular carcinoma. He had been prescribed cyproterone (Androcur) for 20+ years as an anti-libidinal agent, with regular blood tests monitoring …
71y · Male·Complications of metastatic squamous cell carcinoma (terminal palliation)
…on identified in April 2019 that was never re-excised; unacceptable delays in investigating a neck mass (ultrasound not arranged despite recognition of need to exclude sinister pathology); and reliance on a flawed 'paper…
71y · Female·Ruptured abdominal aortic aneurysm, with coronary artery atherosclerosis contrib…
… becoming dismissive of the local doctor; (3) the retrieving doctor (Dr J.) performed an inadequate FAST ultrasound, over-relied on a negative result, and incorrectly prioritized sepsis as the working diagnosis; (4) crit…
18y · Male·Drug toxicity (3,4-methylenedioxy-N-methylamphetamine (MDMA), methylone)
An 18-year-old male died from drug toxicity (MDMA and methylone) following ingestion at a music festival. He collapsed 4 hours after consuming three MDMA capsules over one hour, suffered cardiac arrest at the festival me…
28y · Female·3,4-methylenedioxy-N-methylamphetamine (MDMA) and ketamine toxicity
Trang Thi Thu Le, 28, died on her birthday from MDMA and ketamine toxicity after attending an electronic dance music event at John Cain Arena. She collapsed after consuming drugs purchased from an unknown source within t…
68y · Male·surgical complications following laparoscopic cholecystectomy for cholecystitis,…
Cyril Churchill, a 68-year-old man with multiple comorbidities, died from surgical complications after laparoscopic cholecystectomy for acute cholecystitis. Postoperatively, he developed profound hypotension. The treatin…
0y · Female·acute blood loss due to velamentous insertion of the umbilical cord with likely …
A neonate died from acute blood loss due to velamentous insertion of the umbilical cord with likely vasa previa, a rare condition causing vulnerability to catastrophic bleeding. Key clinical lessons include: (1) prenatal…
41y · Male·large volume thrombotic stroke within the distribution of the right posterior ce…
A 41-year-old man with acute posterior circulation stroke was misdiagnosed as encephalitis despite normal lumbar puncture findings. The critical failure was Dr R.'s failure to diagnose stroke on 7 September and arrange u…
77y · Male·Stroke; cardiogenic shock; severe aortic stenosis with three vessel coronary art…
…and imaging from referring hospital; failure of the proceduralist to review available prior angiographic/ultrasound imaging; and importantly, a 9-hour delay in medical review when Mr Neitsch developed chest pain with acu…
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