50y · Male·ischaemic heart disease
…lated intoxication rather than recognising a medical emergency. Key failure: police did not apply the Brief Coma Scale to assess his impaired consciousness, which would have mandated immediate medical assistance. While t…
18y · Male·multiple injuries
… trauma injuries in motor vehicle accidents, particularly ejection from vehicles; the importance of Glasgow Coma Scale assessment and early airway management; recognition that massive transfusion protocols and aggressive…
81y · Female·Subdural haemorrhage from fall with exacerbation by anticoagulant therapy
An 81-year-old woman with atrial fibrillation and Alzheimer's disease fell at home on 21 December 2020, sustaining a subdural haematoma. Nambour Hospital appropriately ceased her anticoagulant (rivaroxaban) and planned c…
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
…tions were not performed at required frequencies despite policy mandates; (2) a significant drop in Glasgow Coma Scale from 14 to 8 at 7am was not escalated or acted upon; (3) head injuries were not re-assessed despite b…
34y · Female·aspiration pneumonia in the setting of pseudo-obstruction of the large bowel
…aspiration pneumonia following feed commencement via PEG tube, she developed seizures, maintained a Glasgow Coma Scale of 3-4, and was unable to clear secretions. Palliative care was involved and comfort measures impleme…
19y · Male·Toxic effects of multiple drugs, primarily gammahydroxybutyric acid (GHB), causi…
…s alcohol use should trigger overdose suspicion during drug warrant execution; (2) snoring does not exclude coma or respiratory depression; (3) police officers lacked training in recognising drug overdose symptoms; (4) t…
57y · Male·Right acute subdural haematoma following a fall
Gary Desmond Frost, a 57-year-old man with intellectual disability, dementia, and schizophrenia, died from a right acute subdural haematoma following a fall while in supported residential care. He experienced multiple fa…
40y · Male·aspiration pneumonitis with acute alcoholic hepatitis, pancreatitis, mixed drug …
…ground vomitus. Despite resuscitation and ICU support at North West Regional Hospital, he died with Glasgow Coma Scale 3 and severe metabolic acidosis. The coroner found no preventable factors or recommendations for impr…
30y · Male·Unascertained; likely cardiac arrhythmia
…ion or consciousness, did not attach a cardiac monitor despite the patient being unconscious with a Glasgow Coma Score of 3, and demonstrated no sense of urgency. This denied the patient any potential chance of survival,…
58y · Male·Multifocal hepatocellular carcinoma due to cirrhosis of the liver due to hepatit…
… the Secure Unit where nursing staff noted a persistently elevated heart rate and a 3-point drop in Glasgow Coma Scale score, both meeting criteria for calling a code blue, but this was not done. He deteriorated overnigh…
61y · Female·Multiple drug (tapentadol, morphine, diazepam, citalopram) intoxication
… progressive narcotisation throughout the day. Margaret developed respiratory depression, organ failure and coma. The coroner found the death preventable—hospital admission with regular vital sign monitoring and opioid o…
28y · Male·Acute Dopamine Imbalance Syndrome
…argeted neurological assessment despite known abnormal EEG and recent antipsychotic initiation. His Glasgow coma score collapsed from 13 to 5 during this period. He was transferred to ICU, intubated, and died. The cause …
72y · Male·Subarachnoid haemorrhage in a man with coronary arteriosclerosis
…den, catastrophic subarachnoid haemorrhage with no prior specific warning signs, deteriorating from Glasgow Coma Scale 15/15 to 3/15. Neurosurgical review confirmed the haemorrhage was unsurvivable and no surgical interv…
26y · Male·Closed head injury with extradural and subdural haemorrhage resulting from a sku…
…r police ambulance transfer, he was admitted to Royal Darwin Hospital's emergency department with a Glasgow Coma Score of 12, which improved to 15. Despite presenting with signs of serious head injury (bruising, haematom…
10y · Female·Head injuries due to fall from a bunk bed
…r D.—a junior house officer 19 hours into a 24-hour shift—failed to properly examine her, perform a Glasgow Coma Score assessment, consider significant head injury, or refer her for specialist assessment. He discharged h…
65y · Male·Intracranial haemorrhage following a fall
Angelo Palma, a 65-year-old man with intellectual disability living in supported accommodation, fell from bed early morning on 2 October 2015 after reporting feeling unwell and vomiting. He sustained a large left-sided a…
74y · Male·traumatic closed head injuries
…uonville on 28 November 2022. He was transported to Royal Hobart Hospital where he was placed in an induced coma in intensive care but succumbed to his injuries on 2 December 2022. The coroner found the death resulted fr…
66y · Male·Aspiration pneumonia complicating a seizure in a man with dysphagia and phenylke…
…y. He presented to St Vincent's Hospital in status epilepticus with aspiration pneumonia, where his Glasgow Coma Scale fluctuated between 5-9 despite active treatment including IV antibiotics and multiple MET calls. He w…
88y · Male·acute traumatic left cerebral convexity subdural haematoma
An 88-year-old man with age-related cerebral atrophy fell at home on 10 August 2022, injuring his thumb. He presented to the ED alert and orientated, denying head strike or loss of consciousness. His thumb dislocation wa…
85y · Male·pneumonia
…iotic therapy. On 28 January 2016, he was found with altered mental status, tachypnoea, and reduced Glasgow Coma Scale (6/15), with chest X-ray showing left-sided consolidation. He was transferred to St Vincent's Hospita…
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