14y · Male·complications of cerebral arterial gas embolism due to SCUBA incident
… retrieved from the water, but treatment was severely compromised by multiple preventable factors: no 100% oxygen was available on the dive boat; he received inadequate oxygen therapy in hospital (less than 40% inspired …
46y · Male·Aspiration pneumonia complicating epistaxis in the setting of prolonged nasal pr…
…spiration pneumonia, died from aspiration pneumonia complicating epistaxis following prolonged nasal prong oxygen therapy. During a 20-day hospital admission for cholangitis and aspiration pneumonia, nasal pressure injur…
91y · Male·pneumonia on a background of chronic congestive cardiac failure and chronic obst…
…gitation and dyspnoea. Admitted with pneumonia and delirium, he exhibited combative behaviour and resisted oxygen therapy despite dangerously low saturations. A Level 1 Mental Health Act order was placed to enable treatm…
81y · Male·Oxygen deprivation and carbon dioxide toxicity in a person with chronic respirat…
Douglas Ian Scott, an 81-year-old with emphysema, died from oxygen deprivation and carbon dioxide toxicity after smoking while using a home oxygen concentrator. He had been …
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…
68y · Male·Chronic lung disease
…while in lawful custody at Fairfield Nursing Home. He had end-stage COPD and emphysema requiring long-term oxygen therapy and palliative care. The coroner examined whether appropriate care was provided during his detenti…
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 …
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 …
70y · Male·bronchopneumonia in a man with intra-abdominal carcinoma and multiple co-morbidi…
… 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 recognition of acute cor…
48y · Male·unascertained
…diagnosed shortly before admission. During his psychiatric admission, he remained non-compliant with CPAP therapy due to agitation and psychosis. His oxygen saturations were monitored regularly and remained borderline (…
59y · Male·Pneumonia in a man with Lennox-Gastaut syndrome
…admitted to hospital on 6 October with respiratory acidosis and chest X-ray showing consolidation. Despite oxygen therapy and oral antibiotics, his condition deteriorated and he died on palliative care. The coroner found…
62y · Male·Pneumonia in a man with multiple comorbidities
…le on antibiotics. However, on 15 September his condition deteriorated with increased respiratory rate and oxygen requirements despite planned antibiotic de-escalation. He was reassessed as pre-terminal on 16 September a…
Male·non-specific interstitial pneumonia
…ogression of his lung disease. Throughout his 17-month imprisonment, Sharpe made multiple complaints about oxygen supply and medical care adequacy, claiming restrictions on access. Coroner's investigation found his alleg…
63y · Male·respiratory failure in a man with lung cancer, chronic obstructive pulmonary dis…
…nd poor insight into his conditions. Despite heavy smoking (30 cigarettes daily) that he refused to cease, oxygen therapy was contraindicated due to safety risks and lack of capacity to tolerate it. A multidisciplinary t…
85y · Male·ischaemic heart disease
…d dementia. Admitted with acute chest pain and difficulty breathing, he became distressed and was refusing oxygen therapy. A Level 1 Inpatient Treatment Order was authorised to facilitate treatment. Communication was sev…
40y · Male·ischaemic heart disease due to left ventricular hypertrophy and coronary artery …
… complicated by ventricular fibrillation while in custody. He reported chest pain at 11:04 PM and received oxygen, aspirin, and GTN by paramedics who arrived at 11:40 PM. He arrested during transport and could not be res…
49y · Male·Acute bronchopneumonia as a consequence of recent intracranial and intra-cerebra…
…ronto-parietal contusions and subdural haematoma. Despite appropriate medical care including anti-seizure therapy and transfer to HDU with high-flow oxygen therapy, he developed aspiration pneumonia due to hepatic encep…
54y · Female·Respiratory failure secondary to pneumonia, due to multiple sclerosis
…4, was admitted to hospital, and received a MET call for hypoxia. She was transferred to ICU for high-flow oxygen support. Over two days her condition showed minimal improvement, and following discussions with family, sh…
76y · Male·Pleuropulmonary Malignancy on the background of End-Stage Obstructive Pulmonary …
…cant long-standing health problems including COPD related to smoking and asbestos exposure, requiring home oxygen prior to incarceration. A lung mass suspicious for malignancy was identified on imaging in 2020; he was de…
47y · Male·Pneumonia
…multilobar pneumonia. Despite severe sepsis, multiple MET calls, and ICU reviews, he struggled to tolerate oxygen therapy due to distress and repeatedly removed his mask. Goals of care were discussed with family, and he …
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