11y · Female·Pneumonia complicating cerebral palsy secondary to KCNQ2 developmental and epile…
…, epilepsy, and multiple complex medical conditions including central respiratory depression and recurrent chest infections. She died from pneumonia at home in August 2023 after a 12-month period of global neurological …
79y · Female·Aspiration pneumonia in a woman with COVID-19 and multiple medical co-morbiditie…
…icated by COVID-19. She was admitted to hospital in October 2022 with recurrent aspiration pneumonia. A PEG tube was inserted after discussion with family. Following accidental dislodgement during a witnessed roll-out of…
31y · Male·Aspiration Pneumonia
…ng deterioration at a DHHS residential facility and died four days later. A pathologist noted a nasogastric tube appeared coiled in his mouth, but subsequent clinical review confirmed the tube was correctly positioned on…
56y · Female·Aspiration Pneumonia in the setting of Cerebral Palsy and Epilepsy
…priately identified aspiration risk and recommended nil oral intake on 24 May. However, nasogastric feeding tube insertion on 29 May precipitated instability. Surgery was deemed too risky given her physiological state. C…
58y · Male·aspiration pneumonia complicating sigmoid volvulus, in a man with multiple scler…
…, presented to Box Hill Hospital on 25 January 2023 with abdominal pain and distension. He underwent rectal tube insertion via sigmoidoscopy on 26 January with initial improvement. However, he developed aspiration pneumo…
38y · Female·peritonitis with septic shock secondary to perforation of the gastrointestinal t…
… caused by perforation at the gastrostomy stoma site. The perforation likely occurred during difficult reinsertion of a dislodged PEG tube on 21 March 2001. Clinical lessons include: (1) A casual medical officer's asses…
63y · Male·Aspiration pneumonia in the setting of functional decline in a man with an intel…
…ore proactive swallowing assessment, and earlier consideration of non-oral nutrition (attempted nasogastric tube insertion on 25 June was resisted) may have altered outcomes. Documentation of weight loss and falls histor…
85y · Female·sepsis, with aspiration pneumonitis being an antecedent cause. Iatrogenic injury…
…nd electrolyte disturbances after refusing oral intake from hospital day 5 onwards. A fine-bore nasogastric tube was inserted on 30 April 2016 to provide enteral nutrition but was incorrectly positioned in the right lung…
57y · Male·sepsis and multiple organ failure secondary to aspiration pneumonia
…l bowel ileus after presenting with vomiting and diarrhoea. Following emergency laparotomy, his nasogastric tube was dislodged on 29 August and not reinserted during the morning ward round despite clinical stability. Lat…
20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…
…e collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged. Clinical staff performed unnecessary bronchoscopy, misinterpreting findings as a partial …
82y · Male·Pneumonia in an elderly man with advanced lung cancer (squamous cell carcinoma)
…ad a subsequent stroke increasing aspiration risk. He was deemed high-risk for aspiration and a nasogastric tube was not tolerated. Conservative palliative management was appropriately chosen given his mental state and c…
16y · Male·transection of the liver and laceration of the inferior vena cava sustained in a…
…factor. Emergency management was appropriate: rapid transport to hospital, aggressive fluid resuscitation, chest tube insertion, and emergency surgery were all timely and well-executed. Despite three blood transfusions …
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 com…
58y · Male·Gastrointestinal haemorrhage due to erosive gastritis
…lth deterioration requiring lifelong institutional care. In April 2004, he was admitted to hospital with a chest wall haematoma requiring surgical evacuation. Post-operatively, he developed vomiting of coffee-ground mat…
51y · Male·Complications of aspiration pneumonia in a man with status epilepticus
… syndrome and impaired swallowing; maintaining enteral nutrition access is challenging when patients remove tubes; and palliative care discussions should occur early in irreversible deterioration. The case illustrates na…
38y · Male·abdominal and chest sepsis complicating iatrogenic left pneumothorax and laparot…
…ery. Post-operatively he aspirated, developed aspiration pneumonia and septic shock. During central line insertion for inotrope support, an iatrogenic left pneumotharax occurred. The coroner found the care provided by b…
11y · Female·pneumonia complicating cytomegalovirus embryopathy
Queenie Michaels, an 11-year-old Aboriginal girl with cytomegalovirus embryopathy and severe physical and cognitive disabilities, died from pneumonia at home while in government care. She had been fostered by Mr and Mrs …
5y · Female·Pneumonia as a complication of septo-optic cerebral dysplasia
…care under joint guardianship from age 10 months. Over 18 months prior to death, she experienced recurrent chest infections with increasing frequency. She was admitted to Alice Springs Hospital on 15 February 2005 with …
20y · Male·hypoxic encephalopathy
…hy after sustaining head injuries in a motor vehicle collision. While hospitalised in ICU, his endotracheal tube (ETT) became displaced around 12:20am on 23 January 2005, likely moving upward initially with the cuff at o…
76y · Female·Aspiration pneumonia and cholangitis; obstructive jaundice from intraduct tumour…
…tted with obstructive jaundice and sepsis, underwent ERCP procedures for bile duct obstruction and stent insertion. Despite antibiotic therapy and supportive care including transfusion and oxygen therapy, she developed …
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