76 results for “cannulation”
<1y · Male·Sepsis
… to involve senior staff early despite recognising sepsis in a high-risk neonate, multiple unsuccessful cannulation attempts without timely escalation to intraosseous or intramuscular administration, and communication b…
66y · Female·retroperitoneal haemorrhage due to anticoagulation following right cerebrovascul…
A 66-year-old woman died from retroperitoneal haemorrhage following anticoagulation for stroke caused by intra-arterial central venous catheter placement. The catheter was mistakenly inserted into the right carotid arter…
60y · Female·Penetrating injury of the descending thoracic aorta complicating spinal stabiliz…
…g thoracic aorta sustained during spinal stabilisation surgery for a T12 burst fracture. During pedicle cannulation, the surgical awl fractured the left T11 pedicle and plunged superiorly, causing acute blood loss of 30…
<1y · Female·Perinatal asphyxia
Baby XY, a 41-week-old newborn, died from perinatal asphyxia six hours after birth at Sunshine Hospital. The primary clinical lesson involves diagnostic failure: the mother was not diagnosed with gestational diabetes dur…
35y · Female·hypoxic brain injury, with strangulation being an antecedent cause
Blair Dalton died from hypoxic brain injury following strangulation by her partner LP on 26 September 2017. She was resuscitated at the scene and admitted to Gosford Hospital ICU but suffered irreversible brain injury. L…
<1y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…
A 10-month-old boy died following elective cleft palate repair surgery complicated by post-operative respiratory distress and subsequent cardiorespiratory arrest. Initial laryngospasm led to suspected post-obstructive pu…
52y · Male·Metastatic neuroendocrine carcinoma
Darren Rodney Taylor, a 52-year-old Indigenous man, died in custody from metastatic neuroendocrine carcinoma diagnosed in March 2017. He presented with abdominal pain initially attributed to constipation, then found to h…
47y · Female·Mycoplasma pneumonia secondary to rhinovirus infection
Christine Klofa, a 47-year-old woman with Down syndrome and multiple comorbidities, died from mycoplasma pneumonia secondary to rhinovirus infection. She presented to her GP on 6 June with upper respiratory symptoms and …
26y · Male·acute cocaine and alcohol toxicity
AAB, a 26-year-old man with a history of substance abuse and mental health issues, died from acute cocaine and alcohol toxicity while in police custody. He presented to a hotel with agitated, paranoid behaviour and was d…
39y · Female·Respiratory failure in the setting of aspiration pneumonia in a woman with arthr…
…ppropriate throughout. The CPU review identified no misdiagnosis or mistreatment. Family concerns about cannulation difficulties, staff changeover, and treatment distress were attributed to underlying pathology and hosp…
1y · Female·echovirus type 9 infection (myocarditis and pneumonitis)
A 19-month-old child died of echovirus type 9 myocarditis and pneumonitis after rapid deterioration while on holiday. She presented to a small rural hospital with fever, altered consciousness, and seizure activity. The t…
58y · Male·Septic shock secondary to intra-abdominal collections as sequelae of osteomyelit…
A 58-year-old man with Down syndrome and multiple comorbidities died from septic shock secondary to intra-abdominal collections caused by osteomyelitis/discitis of the spine. He initially presented with a foot bone infec…
<1y · Female·subgaleal haematoma complicating an obstructed labour
Vanessa Li, a term infant born following obstructed labour, died at four days of age from subgaleal haemorrhage (SGH) with severe hypoxic-ischaemic encephalopathy. Labour was managed by private obstetrician Dr K., who wa…
51y · Male·Coronary atherosclerosis
A 51-year-old Aboriginal man with a 26-year prison history died from coronary atherosclerosis while incarcerated. He had extensive cardiac disease documented since 1996, with multiple heart attacks in 2011-2012, yet rema…
26y · Female·Stab wounds to the abdomen and back
Ms Ngoc Bao Vy Tran, 26, died from stab wounds inflicted by her intimate partner Stephen Nguyen on 30 September 2021. She received appropriate emergency medical care and resuscitation at Dandenong Hospital but died from …
43y · Male·Coronary Atherosclerosis
Andrew Emerton, a 43-year-old prisoner with a history of substance abuse and psychiatric treatment, collapsed after vigorous exercise in custody. He called for help reporting shortness of breath and was found unconscious…
39y · Male·Multidrug toxicity (GHB, methylamphetamine, ketamine) in a setting of restraint …
Anthony Parisi, 39, died from multidrug toxicity (GHB, methamphetamine, ketamine) in a setting of police restraint and moderate coronary artery atherosclerosis. He consumed large quantities of GHB and methamphetamine on …
3y · Male·thrombotic microangiopathy
A 3-year-old child died from thrombotic microangiopathy (haemolytic uraemic syndrome) secondary to Shiga toxin-producing E. coli infection, likely acquired from consumption of unpasteurised milk. Early presentation to GP…
25y · Female·complications of opioid toxicity
Ellie Marlene Hare, 25, died from opioid toxicity after injecting methadone on two consecutive nights with Matthew Drake. She was opioid-naïve, having not used regularly for several years. On the morning of her death, Dr…
31y · Female·drowning, deliberately self-inflicted with intention of ending life
Maria Rebekah Wright, a 31-year-old woman with severe borderline personality disorder and chronic suicidality, died by drowning at Howrah Beach, Tasmania on 14 August 2017. She had been discharged from Royal Hobart Hospi…
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