59 results for “oxygen administration”
81y · Male·Chronic lung disease (severe COPD) with atherosclerotic cardiovascular and valvu…
…ement errors. Key clinical lessons: (1) patients with CO2 retention require explicit identification on all oxygen prescriptions and careful titration to target saturations 88-92%, not higher; (2) respiratory depressant m…
70y · Male·bronchopneumonia in a man with intra-abdominal carcinoma and multiple co-morbidi…
…luding cardiac disease, liver cirrhosis, and COPD. Key clinical issues included: (1) unauthorised self-administration of oxygen from Oxiboots without medical supervision, which masked deterioration and delayed recognitio…
0y · Female·bronchopneumonia caused by hypoxic brain damage caused or contributed to by meni…
… and seizures. During resuscitation at a rural GP clinic, a CO₂ cylinder was inadvertently used instead of oxygen for 5-20 minutes. The cylinder was misidentified because it was located in the resuscitation area with tub…
69y · Male·end-stage interstitial lung disease and chronic congestive cardiac failure
…is final admission, he developed delirium, agitation and aggressive behaviour with repeated removal of his oxygen mask despite respiratory distress. A Level 1 Inpatient Treatment Order was appropriately placed to enable …
78y · Female·Tension pneumothorax (surgically managed) due to aspiration pneumonia (bronchosc…
…spital was licensed only for ASA 1-3 patients. The anaesthetist administered high-flow, high-concentration oxygen for over 2 hours, which in a CO2 retainer caused severe hypercarbia and hypercarbic narcosis. Post-operati…
32y · Male·Pulmonary embolism originating from deep vein thrombosis in right calf
…xis was appropriately prescribed. However, the clinical team failed to investigate persistent hypoxia (low oxygen saturations 78-85%) from post-operative day 3 onwards. Critical failures included: incorrect completion of…
3y · Male·Influenza A infection (Type H3N2)
…tion early using osmolality testing—treatments are opposite; (2) never discontinuing essential treatments (oxygen) without medical team consultation; (3) avoiding fixation errors by using basic clinical assessment (check…
47y · Male·Aspiration pneumonia due to or as a consequence of coronary atherosclerosis
… pneumonia with contributing coronary atherosclerosis following routine L5-S1 disc replacement. A critical oxygen desaturation (64%) occurred during transfer from theatre to PACU but was inadequately investigated—the ana…
53y · Male·fentanyl and oxycodone toxicity
…: failure to escalate care via mandated RaDAR protocols despite multiple trigger events (pain scores 9-10, oxygen desaturation to 88%, vomiting, excessive sedation); inadequate monitoring frequency (four-hourly rather th…
19y · Female·echovirus type 9 infection (myocarditis and pneumonitis)
…vulsion, consulted a paediatrician, and arranged urgent transfer. Despite appropriate management including oxygen, antibiotic therapy, intraosseous access, and cardiopulmonary resuscitation, the child arrested during tra…
28y · Female·Anaphylactic reaction to anaesthetic drug (suxamethonium), with underlying coron…
…us substandard clinical decisions—including delayed recognition of anaphylaxis, inadequate vasopressor administration, failure to call for senior assistance promptly, and poor fluid management—the coroner found no eviden…
58y · Male·Multiple injuries occasioned in a motor vehicle accident (broken neck, ruptured …
…te passengers' belongings. Expert evidence established that best practice required full trauma assessment, oxygen administration, intravenous access, and consultation with the District Medical Officer when a patient decl…
49y · Male·Obstructive sleep apnoea, contributed to by the sedating effects of therapeutic …
…eroma. Critical deficiencies included inadequate monitoring of a patient with OSA after benzodiazepine administration, poor record-keeping, and lack of continuous visual observation. The coroner noted the hospital lacked…
68y · Male·Ischaemic heart disease (operated); severe native coronary artery atheroma with …
…tablets taken prior to admission), leading to opioid-related respiratory depression requiring naloxone administration. The coroner concluded his underlying severe cardiac disease was the primary cause of death, and that …
82y · Female·Hyperkalaemia due to acute renal failure on a background of end stage pulmonary …
…as issued. She was admitted to the respiratory ward where her condition was managed for comfort, including oxygen therapy and subcutaneous morphine and sedatives. She died from hyperkalaemia and acute renal failure. Expe…
45y · Female·Metastatic ovarian carcinoma
…a on day 8 of admission and died suddenly on day 10 when she stopped breathing and became cyanosed despite oxygen administration. Autopsy confirmed metastatic ovarian carcinoma as the cause of death. The coroner found he…
69y · Male·Perforated bowel/septicaemia as a result of diverticulitis
…athology (elevated WCC, x-ray findings suggestive of small bowel obstruction, low albumin, tachypnoea, low oxygen saturations); inappropriate enema administration which may have been harmful; delayed x-ray reporting; poo…
87y · Female·heart failure and probable pneumonia in an elderly lady complicated by morphine …
…aïve patients with respiratory failure, consider alternative analgesia, stay to monitor after morphine administration, and verify medication expiry dates.
21y · Male·Hypoxic brain injury arising from severe anaphylactic shock due to administratio…
…aparoscopic appendicectomy. Surgery was routine and uneventful. Upon emergence from anaesthesia, after administration of Sugammadex (neuromuscular reversal agent), Lucas developed severe anaphylactic shock with bronchosp…
43y · Male·Hypoxic ischaemic encephalopathy, due to or as consequence of, cardiac arrest of…
… lethal methamphetamine toxicity with sympathomimetic crisis, the paramedics' failure to provide high-flow oxygen, appropriate airway support, and proper monitoring contributed to cardiac arrest and subsequent brain deat…
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