538 results for “observation”
28y · Male·Neck compression consistent with hanging
…der involuntary detention. Despite being assessed as high suicide risk and assigned Level 2 (15-minute) observations, care was allocated to an unsupervised trainee enrolled nurse. Systematic failures included: routine f…
37y · Female·head injury sustained in motor vehicle collision (pedestrian)
…owever, the finding highlights a systemic issue identified in multiple coronial investigations: nursing observation levels were reduced from 30 to 60 minutes without documented medical practitioner agreement. Eastern He…
50y · Male·upper airway obstruction (choking) from tissue paper
…ntary patient under the Mental Health Act. Although the clinical decision-making regarding his level of observation (every 15 minutes rather than one-to-one constant supervision) was appropriate, supervision was severel…
19y · Female·hypoxic encephalopathy as a result of attempted hanging
…athy following attempted hanging while in involuntary psychiatric admission. She was on R15 (15-minute) observation status due to suicide risk, but observations were not conducted appropriately. A nursing staff member l…
45y · Male·spontaneous lethal arrhythmia arising from focal myocardial fibrosis
…om spontaneous lethal arrhythmia due to focal myocardial fibrosis. Critical issue was inadequate visual observations overnight—the patient had refused physical examination and blood tests on admission. Observations at 7…
36y · Male·Multi-organ failure due to consequences of multiple injuries sustained following…
…s. Within hours, after receiving PRN medication for agitation, he absconded unnoticed due to inadequate observation practices and was struck by a motor vehicle, sustaining multiple injuries including head trauma. He die…
70y · Male·Cyanide Toxicity
…the ED, he was assessed as calm and cooperative, placed in a high-visibility cubicle without one-to-one observation, and absconded at 3:40pm during the busy afternoon shift changeover. Police were notified but without t…
21y · Male·Hypoxic brain injury in the setting of drug toxicity
…S protocol breach), failure to communicate that he had swallowed a package containing drugs, inadequate observation during 75-minute placement in holding cell where deterioration was not appreciated, and failure to asse…
27y · Male·HEAD INJURY SUSTAINED IN A MOTOR VEHICLE COLLISION (PEDESTRIAN)
…g intent to jump from a moving car and requesting High Dependency placement. He was placed on 15-minute observations but absconded via the courtyard fence within 45 minutes and was struck by a truck. Clinical lessons: d…
28y · Male·hanging
…lucinations commanding self-harm and had made previous suicide attempts. Despite being assigned 'close' observation level requiring 15-minute checks, the ward's actual checklist only provided hourly checks after 21:30 h…
27y · Male·Hanging
… stated intention to hang himself, was admitted to Arthur Gorrie Correctional Centre's medical unit for observation as an 'at-risk' prisoner. Four days later, he died by hanging using a bed sheet attached to exposed win…
23y · Male·Hanging
…cy governed bathroom access; staff practice was inconsistent. A Psychiatric Nurse failed to complete an observation at 10:15 AM as required, documenting that he had seen the patient when he had not. However, this false …
25y · Male·hypoxic-ischaemic brain injury due to plastic bag asphyxia
…nother patient, he was transferred to H Floor on 11 October 2003, where he was placed under a 15-minute observation protocol following an involuntary treatment order. On 15 October, he was found with a plastic bag over …
54y · Male·Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking
…e to nursing staff; failure to communicate with the patient every 15 minutes as required; and haphazard observation documentation not reflecting actual practice. The CCTV footage showed the patient collapsed motionless …
75y · Male·Hanging
…ferred to Alfred Hospital then returned with one-to-one nursing. On 2 October, his one-to-one overnight observations were discontinued by Dr T. as he had not expressed further self-harm ideation. He died by hanging on 4…
73y · Male·Neck compression in the circumstances of hanging
…nt. While preventive interventions might not have succeeded, better risk reassessment, engagement-based observation protocols, and environmental safety measures were deficient. The coroner emphasises that observation sh…
Female·multiple injuries due to a fall from height (suicide by jumping from multi-store…
…andra Hospital then transferred to Belmont. Critical failures included: a nursing unit manager reducing observation frequency from 15 to 30 minutes without doctor approval; unclear communication about 'nil leave' restri…
36y · Male·Hanging
… Gorrie Correctional Centre on 19 September 2006. He was on a risk management plan requiring two-hourly observations due to low-risk suicide concerns but was not observed between 5:30pm and 9:00pm on the day of death du…
28y · Male·neck compression subsequent upon hanging
…cute Unit at Ballarat Health Services following deteriorating mental health and was placed on 30-minute observations as a new admission. Critical failures occurred: nursing observations were not properly conducted—staff…
51y · Male·Combined effects of atherosclerotic cardiovascular disease and seizure activity …
… referral or EEG); anti-convulsant levels were subtherapeutic; and inadequate documented care plans and observation protocols followed the Code Blue incident. The prison subsequently implemented improved documentation s…
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