44 results for “oxygen saturation monitoring”
50y · Male·Multiple pulmonary thromboemboli due to deep vein thrombosis following pharyngea…
…lure to ensure continued CPAP use despite surgeon and anaesthetist expectations, and absence of continuous oxygen saturation monitoring. The patient suffered undetected hypoxia overnight, leading to respiratory arrest an…
84y · Female·left lower lung bronchopneumonia in conjunction with small distal pulmonary embo…
…dities sustained right shoulder and pelvic fractures from an accidental fall. She presented to ED with low oxygen saturation (77%) requiring supplemental oxygen. Despite these injuries and age-related vulnerability, she …
72y · Male·Bilateral pneumothoraces and pneumoperitoneum due to insufflation of the bladder…
…ection, died from bilateral pneumothoraces and pneumoperitoneum caused by insufflation of his bladder with oxygen. The oxygen supply tubing was somehow connected to his urinary catheter instead of nasal cannula, causing …
52y · Male·Aspiration pneumonia in a man with end stage Huntington's disease
…iple times in 2024. In late August, he contracted COVID-19 with respiratory symptoms. On 26 September, low oxygen saturation (85-87%) was noted and a locum reviewed him via video, prescribing antibiotics with advice to h…
66y · Female·Hypoxic-ischaemic encephalopathy
…erwent routine knee surgery at Royal Darwin Hospital. Post-operative care was inadequate. Despite dropping oxygen saturations to 88% when sedated and requiring frequent rousing, she was discharged from PACU with modified…
26y · Male·Coronary artery atherosclerosis in the setting of schizoaffective disorder
…d 29 November), zuclopenthixol, olanzapine, sodium valproate, and diazepam. Quetiapine was noted to affect oxygen saturation and required close supervision. The autopsy revealed severe coronary artery atherosclerosis. No…
20y · Female·cardiac dysrhythmia/arrest in a 20 year old Down's Syndrome female following abd…
…gistrar 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 known seve…
17y · Male·fatal asphyxia resulting from severe upper airway obstruction secondary to acute…
…elephone without medical review for over 5 hours. Critical vital signs deterioration was identified at 2am—oxygen saturation dropped to 88% and respiration rate increased to 26—but nursing staff failed to escalate approp…
31y · Male·Status epilepsy secondary to cerebral cavernoma
…ered cardiac arrest. The coroner found paramedic care appropriate despite expert commentary that earlier monitoring equipment application, earlier lateral repositioning, and closer airway assessment could have been benef…
70y · Male·Acute coronary occlusion due to extensive coronary atherosclerosis
…rst-year intern (Dr T.) apparently making discharge decisions without documented senior review; inadequate oxygen saturation monitoring documentation (91% room air at admission not clearly improved at discharge); and poo…
54y · Female·Opioid toxicity (predominantly fentanyl)
… not communicated to Dr Y.. The patient vomited medications on the evening of 9 July and developed reduced oxygen saturation (94%), but was re-dosed with methadone without escalation to the anaesthetist. She was found un…
46y · Male·Cardiomegaly in the setting of hypoventilation syndrome in an obese man with sch…
…iatric unit on the day he died with handover instructions to monitor vital signs but not routinely measure oxygen saturation. The coroner found no want of care contributed to his death. Key clinical lessons include: the …
33y · Male·Opiate toxicity
…ts—acknowledged as excessive by the physician who now recognizes this was inappropriate practice. Critical oxygen desaturations (79-90%) occurred throughout admission but were not recognized as a contraindication to furt…
42y · Female·Global cerebral ischaemia in a setting of anaesthesia
…nsure a functioning pulse oximeter reading before induction of anaesthesia, despite difficulty obtaining saturation readings while the patient was awake. He administered propofol, fentanyl, and midazolam without baseline…
37y · Male·Community acquired pneumonia as a result of melioidosis infection
…d neutrophils, metamyelocytes, myelocytes) suggestive of severe infection; (3) responding to deteriorating oxygen saturation levels (falling from 90% to 82%) with urgent intervention rather than expectant management; (4)…
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…
48y · Male·unascertained
…his psychiatric admission, he remained non-compliant with CPAP therapy due to agitation and psychosis. His oxygen saturations were monitored regularly and remained borderline (91-95%). His CPAP machine was taken for serv…
58y · Female·pneumonia and cardiac failure complicated by hypoxic brain injury
…mmodation and severe behavioural difficulties. On 3 January 2013, she developed a chest infection with low oxygen saturation (93%). Despite antibiotic changes, she suffered sudden cardiac arrest later that evening. Resus…
<1y · Female·Persistent pulmonary hypertension in the newborn (PPHN)
…mmer died from PPHN but was not satisfied it was caused by sepsis despite low blood sugars and fluctuating oxygen requirements. While Dr M.'s management was generally appropriate, the coroner identified that antibiotics …
71y · Male·aspiration bronchopneumonia as a consequence of traumatic brain injury from a fa…
…onia in the Advanced Care Unit of Southern Queensland Correctional Centre. Critical clinical lessons: when oxygen saturations fell to 77% at 1:33pm, supplemental oxygen was not provided despite being available, no contin…
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