47 results for “neurological examination”
46y · Female·brain swelling and dural venous thrombosis in association with low grade glioma …
…bances. Dr G. diagnosed migraine based on her history and symptoms, but failed to conduct comprehensive neurological examination or assess for papilloedema despite multiple red flags. He did not consider alternative diag…
73y · Male·Complications of cervical fractures and spinal injury (operated), sustained in a…
…imple fall despite dispatch information indicating a potentially dangerous injury. They did not perform neurological examination, moved the patient inadequately, lacked shared decision-making, and allowed cognitive bias …
66y · Male·Undetermined - natural causes; likely sudden cardiac arrhythmia
…in residential care. He complained of neck soreness before the event. Despite comprehensive post-mortem examination including neuropathology, no definitive cause of death was identified. The pathologist noted significan…
12y · Male·astrocytoma (brainstem, posterior fossa tumour with hydrocephalus and brainstem …
…. That evening, he developed vomiting and confusion suggesting 'coning' (brainstem herniation). Despite neurological examination showing apparent recovery, he deteriorated catastrophically at 5:55 am and could not be res…
43y · Female·Hypostatic bronchopneumonia in the setting of birth-related brain injury
…condition severely deteriorated on the morning of death, but she was not for resuscitation. Post-mortem examination confirmed natural causes. The coroner found that Ms Ryan received appropriate and reasonable care. Key …
<1y · Male·Global hypoxic brain necrosis as a result of non-accidental violent shaking of t…
…iolent shaking (shaken baby syndrome). He was examined by a neurosurgeon, Dr C., at 9:30am and appeared neurologically normal. His mother then cared for him until dropping him at day care around 10:40am. He was found unc…
41y · Male·Subdural haematoma
…ation. Critical failures included: cognitive bias anchoring on alcohol withdrawal diagnosis; inadequate neurological examination and documentation; failure to obtain CT imaging despite red flags; continued diazepam admin…
12y · Female·raised intracranial pressure due to ventriculo-peritoneal shunt blockage
…d concerning symptoms including vomiting. Critical communication failures occurred: the doctor assessed neurological examination as more comprehensive than performed, misunderstood observation duration, and the mother wa…
28y · Male·Acute Dopamine Imbalance Syndrome
…admitted to the ED where he spent five hours undergoing vague "physical clearance" rather than targeted neurological assessment despite known abnormal EEG and recent antipsychotic initiation. His Glasgow coma score colla…
76y · Male·Bronchopneumonia in a man with ischaemic heart disease and treated spinal crush …
…ive bilateral lower limb weakness, but recognition was delayed due to severe delirium which complicated neurological assessment. Staff at Frankston Hospital failed to recognise that his neurology had been normal on disch…
77y · Female·Large acute subdural haemorrhage leading to uncal herniation subsequent to an ac…
…al fall in hospital. She fell while using a wheeled walker and initially appeared uninjured with normal neurological examination. However, she developed breathing difficulties and severe headache hours later, which were …
58y · Female·Complications of end stage Alzheimer's disease in a woman with Down syndrome
…58-year-old woman with Down syndrome and end-stage Alzheimer's dementia, died from complications of her neurological conditions. She had been a ward of the state living in Department of Human Services residential housing…
29y · Male·Bronchopneumonia in a man with epilepsy
Hussan Rushton, a 29-year-old man with epilepsy, spastic quadriplegia, dysphasia and cortical blindness in full-time residential care, died from bronchopneumonia. He returned from an outing appearing extremely tired and …
54y · Female·Complications of Lennox-Gastaut Syndrome
…nsive in bed on 22 June 2020, approximately 9.5 hours after last being seen well by carers. Post-mortem examination revealed no unexpected findings. She had been receiving appropriate epilepsy management with documented…
10y · Male·Unascertained - sudden and unexpected death; evidence did not allow determinatio…
…or sudden cardiac death, as evidence was incomplete and inconclusive. The boy had episodes of transient neurological symptoms in April-May 2011 that prompted investigation including ECG, MRI, and echocardiogram, but no d…
59y · Male·Complications of multiple sclerosis
…roughout 2022, and he was found unresponsive on 30 October 2022, passing away that day. The post-mortem examination confirmed natural death from MS complications. This case highlights the importance of appropriate palli…
82y · Male·Intracranial haemorrhage secondary to blunt force trauma (fall)
… was unwitnessed at 8.24am. When examined after a second fall at 7.35pm, nursing staff performed normal neurological observations and did not call a doctor. Critical system failures included: inadequate handover between …
35y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to vertebro…
A 35-year-old woman presented to a rural hospital with a three-day history of collapses, slurred speech, vomiting, and abnormal eye movements. A non-contrast CT head scan was normal, and she was discharged with a diagnos…
82y · Male·closed head injury (subdural haematoma) sustained in a fall
…a urinal bottle, despite falls risk assessment identifying he needed assistance with toileting. Initial examination appeared thorough with normal vital signs and neurological findings, and CT scan was not performed. He …
62y · Male·Aspiration pneumonia complicating epilepsy in the setting of Down syndrome
…the challenge of managing swallowing difficulties and recurrent aspiration in patients with progressive neurological disease, highlighting the importance of proactive aspiration precautions, careful seizure management, a…
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