21 results for “manual ventilation”
0y · Male·Hypoxic ischaemic encephalopathy secondary to post-operative respiratory distres…
…ation alone), investigate gastric distension as a sign of tube malpositioning, maintain capnography during manual ventilation and CPR, and ensure clear airway role assignment during resuscitations.
42y · Male·Hypoxic encephalopathy in the setting of recent acute myocardial infarction with…
…, failure to use a bougie despite difficulty, lack of capnography confirmation, and critically, absence of manual bag-mask ventilation between intubation attempts. The endotracheal tube was misplaced in the oesophagus fo…
47y · Male·Smoke inhalation due to fire
…nufacturer guidelines; guests received inadequate refuelling instructions without access to the operator's manual; a 20-litre jerry can and plastic funnel were provided, increasing spillage and static discharge risk; the…
39y · Male·Complications of large bowel pseudo-obstruction
…bstruction with aspiration pneumonia. He had been admitted involuntarily for acute psychosis and underwent manual rectal dis-impaction and enemas on 2 February 2017. He collapsed with faecal vomiting, aspiration, and bow…
48y · Female·Acute respiratory failure (cerebral hypoxia) in a woman dependent on non-invasiv…
…in, 48, with motor neurone disease, died from acute respiratory failure while dependent on non-invasive ventilation (NIV) at home. A carer, Julie Manessis, was caring for her when the humidifier tipped over, water enter…
57y · Female·Complications of muscular dystrophy
A 57-year-old woman with longstanding muscular dystrophy and newly diagnosed cardiomyopathy died from complications of her underlying condition. She became acutely unwell overnight at her residential support facility wit…
67y · Male·Complicated endotracheal tube insertion due to or as a consequence of recent clo…
…ys of age. Following successful surgical ligation of a patent ductus arteriosus (PDA), Oliver developed ventilation difficulties in the immediate post-operative period. A 3.0mm endotracheal tube (ETT) was selected for i…
8y · Male·Carbon monoxide poisoning
…at CO poisoning from domestic appliances is preventable through regular professional servicing, testing ventilation systems for safety, and avoiding retrofit exhaust fans without gas fitter assessment. Early warning sig…
0y · Male·Complications of VATER syndrome and sacrococcygeal teratoma
…d from complications of these conditions. He was born prematurely at 30 weeks, requiring intubation and ventilation, and remained in Perth Children's Hospital for over 5 months with multiple complex medical conditions r…
Male·David Gurralpa: sudden heart attack (coronary atherosclerosis with long-standing…
Two deaths resulted from police restraint in prone positions. David Gurralpa, a 39-year-old Aboriginal man with pre-existing coronary artery disease, died of sudden cardiac arrest following police restraint during a dome…
0y · 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…
0y · Male·Complications following forceps delivery
A 3-day-old neonate died from complications of instrumental forceps delivery, specifically subgaleal haemorrhage with associated skull fracture and intracranial bleeding. Critical clinical lessons include: (1) complex fo…
85y · Female·acute exacerbation of congestive heart failure, following injuries suffered in a…
Ms Tremethick, an 85-year-old with congestive heart failure, fell at home and suffered a lacerated forearm. Paramedics attended and initially administered methoxyflurane for pain relief. She developed fulminant pulmonary…
51y · Male·Multiple organ failure due to Influenza A pneumonia, in the context of chronic k…
…dures and made no adverse findings regarding clinical care or recommendations for improvement. Key lesson: manual medication re-charting in busy ICUs creates error risk; the unit implemented full-time pharmacist coverage…
31y · Female·Post-partum Haemorrhage associated with Amniotic Fluid Embolism and Uterine Hypo…
Laura Marguerite Sinclair, 31-year-old primigravida, died from post-partum haemorrhage associated with amniotic fluid embolism (AFE) and uterine hypotonia. She underwent emergency caesarean section for foetal distress at…
0y · Male·Complications of birth-related traumatic head injury
Tasman Murray Tribe, a neonate born at 36 weeks gestation, died at 7 days of age from complications of birth-related traumatic head injury. Labour was prolonged in the second stage; instrumental delivery was attempted bu…
20y · Female·Cerebral anoxia consequent upon a severe acute asthmatic event
Sally Anne Gordon, a 20-year-old with a 14-year history of severe brittle asthma, presented to Mount Gambier Hospital on 26 November 2000 with acute severe asthma unresponsive to initial treatment. After appropriate emer…
19y · Male·Traumatic asphyxia
…essons include: (1) traumatic asphyxia causes death within minutes through chest compression preventing ventilation; (2) crush injuries may rapidly become unsurvivable before emergency services arrive; (3) dispatcher pr…
24y · Male·Hypoxic-ischaemic encephalopathy, due to or as a consequence of cardiac arrest, …
Hamid Khazaei, an Iranian asylum seeker aged 24, died on 5 September 2014 after contracting a leg infection (Chromobacterium violaceum) on Manus Island while in immigration detention. His death was preventable and result…
29y · Female·peritonitis caused by ischaemia of the bowel due to gastrointestinal torsion (tw…
Shona Hookey, a 29-year-old Aboriginal woman with severe intellectual disability and aphasia, died of peritonitis secondary to bowel torsion. Critical failures occurred at multiple levels: carers at her group home delaye…
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