36 results for “blood sampling”
Male·Global hypoxic-ischaemic encephalopathy
… CTG interpretation (particularly at 0900 review), absent or poorly communicated care plans, lack of fetal blood sampling despite clinical indication, failure to escalate to senior staff, and communication breakdown bet…
1y · Female·sudden cardiac death on a background of rhinovirus infection
…s (respiratory rate >70, elevated heart rate) as requiring escalation despite fever; (3) the importance of blood gas sampling when vital signs deteriorate; (4) implementing Between the Flags vital sign monitoring system…
0y · Female·Peripartum hypoxia
… apply despite fetal anomalies; inadequate handover communication of the management plan; absence of fetal blood sampling despite prolonged abnormal CTG; multiple consultant involvement without clear leadership; and del…
18y · Male·multiple injuries
…rom the vehicle and suffered a closed head injury with subdural haematoma and severe pelvic fractures with blood loss. First aid at the scene was appropriate given his catastrophic injuries. Key clinical lessons: the se…
75y · Female·Haemorrhage due to chest and abdominal injuries sustained in motor vehicle colli…
…ision on 29 June 2010. The crash occurred when Ms Tanya Smith, driving under the influence of alcohol (6-7 Bloody Marys over 4 hours), swerved onto the wrong side of the road into the path of Mr Bruce Thompson's vehicle…
70y · Female·Cause of death could not be determined - available evidence does not allow a fin…
…es without adequate medical investigation, and the critical need for external examinations and toxicology sampling when sudden unexpected deaths occur in potentially suspicious circumstances.
0y · Female·Persistent pulmonary hypertension in the newborn (PPHN)
…al. The coroner found Baby Summer died from PPHN but was not satisfied it was caused by sepsis despite low blood sugars and fluctuating oxygen requirements. While Dr M.'s management was generally appropriate, the corone…
0y · Female·Fetal demise due to placental abruption and sepsis secondary to chorioamnionitis…
Ashlee Reindl died hours after birth in 2019 following a prolonged induction of labour complicated by fetal distress and chorioamnionitis. A catastrophic placental abruption occurred shortly before emergency caesarean se…
71y · Female·massive acute haemolysis leading to severe anaemia and multi-system failure as a…
Ruth Stoll, 71, died from massive acute haemolysis and multi-system failure after receiving incompatible blood transfusions during aortic aneurysm repair. Pre-operative blood samples from Stoll and another patient (Ko…
0y · Female·Cerebral hypoxia due to placental abruption
Sophie Sparreboom died from cerebral hypoxia secondary to placental abruption following emergency caesarean section. Gestational diabetes indicated planned induction at term. At 2050 hours, antepartum haemorrhage and pat…
43y · Male·Undetermined — available evidence does not allow determination due to limitation…
… organs were not removed or weighed, no radiological imaging was performed, and no photographs were taken. Blood carbon monoxide of 8% (within normal range) suggested possible death before fire commenced. The fire cause…
89y · Male·combined effects of cerebrovascular accident, pneumonia and chronic cardiac fail…
An 89-year-old man with multiple comorbidities (ischaemic heart disease, diabetes, COPD) presented with chest infection and was admitted for heart failure. He suffered an acute stroke with subsequent delirium and combati…
0y · Female·Methylamphetamine toxicity
A newborn baby died 8 hours after birth from methylamphetamine toxicity acquired in utero. The mother unknowingly consumed methylamphetamine in the days before labour, likely by drinking from a contaminated bottle at a r…
41y · Male·multi-organ failure and staphylococcal septicaemia following pulmonary and aorti…
… with fever and chest pain but was initially misdiagnosed as having viral infection. Following appropriate blood tests revealing thrombocytopenia, he was admitted to RAH. He absconded after 24 hours, returning to the co…
0y · Female·subgaleal haematoma complicating an obstructed labour
…SGH was not identified until 7.30am, approximately 6 hours after birth. Earlier recognition and aggressive blood pressure support may have prevented deterioration, though outcome was likely poor. Key lessons: always com…
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…
0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the sett…
…dditional delays occurred between decision (2:02 pm) and theatre commencement (3:31 pm) due to waiting for blood results and fasting confirmation, and a junior doctor was permitted to attempt spinal anaesthesia during a…
61y · Male·Pneumonia
Kenneth Morrison, a 61-year-old man with Down's syndrome, dementia and multiple comorbidities, died from pneumonia following hospitalisation at Casey Hospital in March 2008. Community Residential Unit (CRU) carers raised…
58y · Female·cardiac arrhythmia caused by a combination of pre-existing myocarditis and the a…
…monitoring protocols were appropriately followed. The key clinical lesson relates to improved post-mortem sampling procedures for patients on clozapine.
72y · Female·Peritonitis due to perforated diverticulum in transverse colon
…tion deteriorated markedly from approximately 22:00 hours on 6 February 2003, with progressively declining blood pressure (85/56 to 70/53) and hypoxia. However, these vital sign changes were attributed to mechanical deh…
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