382 results for “intensive care monitoring”
20y · Female·cardiac dysrhythmia/arrest in a 20 year old Down's Syndrome female following abd…
…ered by registrar without senior consultant present despite extreme anaesthetic risk; failure to provide intensive monitoring (ECG, continuous oximetry) post-operatively despite preoperative oxygen saturation of 48% and…
45y · Female·Epilepsy
… She was found fitting, became unresponsive and apnoeic with asystolic arrest. Despite effective CPR and intensive care management including intubation and anti-seizure medication loading, she had severe hypoxic brain i…
Male·Myocardial failure resulting from excessive pulmonary blood flow and consequenti…
…ow. The coroner identified several clinical management concerns: absence of blood pressure and blood gas monitoring during prostaglandin administration; possibly excessive prostaglandin dosing that created an imbalance f…
43y · Male·Multi-organ failure with coagulopathy secondary to acute exacerbation of chronic…
…s with symptomatic obstructive hydrocephalus at risk of rapid deterioration require ICU-level continuous monitoring, not general ward care; (2) deteriorating neurological symptoms warrant urgent surgical intervention, no…
54y · Male·Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking
…phrenia died of hypoxic-ischaemic brain injury from choking on food whilst in seclusion in a psychiatric intensive care unit. Key failures included: unsupervised provision of food to a patient with poor dentition and se…
0y · Male·cardiogenic shock and neonatal encephalopathy
…of age at Flinders Medical Centre, died from cardiogenic shock and neonatal encephalopathy. While obstetric care was appropriate, neonatal care was significantly deficient. Critical failures included: failure to insert a…
61y · Male·Undetermined
…rmined cause. Clinical lessons include: Eastern Health sedation guidelines were not followed; vital sign monitoring ceased at 7:45am on 4 April despite guidelines requiring observations for 72 hours; no ECG was performed…
43y · Male·Pneumonia
…r found medical management reasonable and appropriate, but commended subsequent improvements in sedation monitoring policies and training.
24y · Male·Aspiration of vomit associated with combined drug effect
…ased to home detention on 27 December 2000, he struggled with marital difficulties, accumulated multiple monitoring breaches (36 telephone alerts), tested positive for amphetamines, and attempted suicide on 4 January 200…
49y · Male·combined drug toxicity
…, methylamphetamine, and cannabis). He was managed on a Community Treatment Order in the community by an Intensive Clinical Outreach Team. While the coroner found his care reasonable overall, the finding identifies that…
24y · Male·multiple stab wounds to the chest that he inflicted upon himself
…ptoms re-emerge or medication is discontinued, and close liaison between mental health services and primary care. Home visits and family engagement might have prevented relapse. The death was self-inflicted and not preve…
50y · Female·Aspiration pneumonia, with epilepsy with frequent seizures as contributory cause
…fer to a tertiary hospital. She was extubated the following morning, transferred to the ward for routine monitoring, and found unresponsive that evening. The coroner found the care received in the period proximate to dea…
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
…pital ED with sepsis on 21 March 2016 and died 22 March 2016. Expert review identified multiple sub-optimal care deficiencies: inadequate urine output monitoring (no urinary catheter despite critical illness and acute ki…
33y · Male·Decompensated congestive cardiac failure complicating acute myocardial infarctio…
…ronary syndrome with elevated troponin. However, cardiogenic shock developed during admission, requiring intensive haemodynamic support. Medical experts identified that prescribing beta-blocker on day 2 was an error in …
0y · 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…
84y · Male·Pneumonia complicating fractured cervical spine in the setting of fall
…ure from a fall on a bus. Following the acute traumatic injury, he was appropriately managed in ICU with monitoring of respiratory function and conservative treatment with dexamethasone. Pneumonia developed later and was…
64y · Female·fatal cardiac arrhythmia in a lady with obstructed sleep apnoea, obesity and suf…
…hypoxia (oxygen saturation 93%) and requiring supplemental oxygen overnight, she was transferred to an aged-care psychiatric ward (Banksia Ward) the following afternoon. At 3.10 pm she received an intramuscular olanzapin…
20y · Male·anoxic brain injury following cardio-respiratory arrest caused by hypoxia result…
… Key learning: patients with impaired consciousness and tracheostomies require continuous pulse oximetry monitoring rather than intermittent suctioning alone. Poor nursing documentation and unclear nursing care standards…
29y · Female·Hypoxic-ischaemic encephalopathy due to cardiac arrest of undetermined cause
…ived 5mg droperidol IM for sedation, which was appropriate given her frailty. However, formal vital sign monitoring post-sedation was not undertaken between 07:50-08:00 hours, contrary to work instructions requiring moni…
27y · Male·Head injury
Abdullahi Bashir, 27, died from a severe head injury sustained during an alleged altercation on 7 June 2017. Following a punch to the face, he fell backwards and struck his head on the road. He was taken to a private res…
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