38 results for “specialist appointments”
71y · Female·Diffuse Lymphoid Malignancy
…ot contribute to her death. The case highlights the importance of robust systems to ensure continuity of specialist care for chronically ill patients in custodial settings, and the need for contracted health service prov…
56y · Male·complications of viral hepatitis related advanced-chronic liver disease
…cal management by prison and hospital teams, two system failures occurred: Russell missed a 5 March 2025 specialist appointment due to a prison transfer that disregarded his documented appointment, and his family were no…
35y · Male·Hanging
…While causally unrelated to his death, the coroner identified systemic failures: absence of follow-up on specialist appointments, reliance on Port Phillip Prison as mandatory conduit for secondary care (which deterred tr…
45y · Male·severe chronic obstructive pulmonary disease
…moking. Clinical examination revealed pulmonary fibrosis, emphysema, and pulmonary hypertension. Despite specialist referral to a respiratory physician and investigation (PET scan, spirometry, imaging), the deceased's co…
Female·Intrauterine pneumonia and meconium aspiration complicating intrauterine growth …
…ritical failures included: absence of systematic substance use screening during early pregnancy, lack of specialist addiction medicine consultation despite known daily amphetamine use, non-attendance at appointments with…
13y · Male·Epileptic seizure with aspiration
…cation non-compliance with topiramate (not detected in toxicology despite prescription); multiple missed specialist appointments; inadequate medication review prior to death; concerning medication prescribing (diazepam t…
41y · Male·Cerebral hypoxia and bronchopneumonia; contributing factors: toxic megacolon, ce…
…d. Key clinical lessons include: (1) constipation in people with intellectual disability requires urgent specialist gastroenterology assessment as it can indicate serious pathology including toxic megacolon; (2) pain in …
35y · Male·serotonin syndrome
…on, with the dose increased from the standard 60-120mg range based on his own self-reporting rather than specialist communication. He was also using illicit methylamphetamine and had been given benzodiazepines. The coron…
47y · Male·bronchopneumonia and upper airway obstruction in a man with end-stage oral cance…
…ve care while in custody, superior to what he received in the community where he was non-compliant with appointments. Efforts were made to arrange bail release or hospital transfer to his home region (Kununurra) in his f…
58y · Male·Hanging
…ath (given the unpredictable nature of suicidality), she identified a lost opportunity for comprehensive specialist assessment. Key clinical lessons include the importance of measuring and monitoring wait times for psych…
53y · Male·Acute myocardial infarction due to triple vessel atherosclerosis and thrombosis …
…ess to interventional cardiology services were contributing factors. The patient's reluctance to attend appointments and commence medications also played a role.
10y · Male·hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…
…-threatening and at "medical emergency intervention stage," his parents failed to attend most follow-up appointments, allowed continued weight gain (18kg in 12 months), and did not consistently use prescribed treatment. …
40y · Male·Gunshot wound to neck
…r expressed concerns about medication-related behavioural changes in March 2019, prompting referral to a specialist who was unavailable. Dr S. attempted urgent specialist referrals but Ben declined appointments due to fi…
55y · Male·Immersion
…njection appointment on 27 February. No coordinated system existed to alert the treating team of missed appointments. He left the accommodation on 7 March and lost all contact with services, remaining unmedicated for mor…
86y · Male·Sepsis associated with a pericolic abscess, complicated by terminal large intest…
…e coroner found his care in custody was appropriate, with adequate medical assessment, nursing care, and specialist review. Key clinical lessons include: recognising that elderly prisoners with multiple comorbidities req…
63y · Male·Hypotensive and atherosclerotic heart disease
…agement within prison constraints, though documentation of blood pressure was inconsistent and discussed specialist referrals were not recorded. The coroner found care acceptable but noted that prisoners deserve equivale…
52y · Male·hanging
…P-level management, policy ambiguities regarding cell checks on public holidays, and delays in accessing specialist respiratory review. The coroner found no single preventable act would have saved his life, but identifie…
36y · Male·infective endocarditis
…nfective endocarditis risk due to IV drug use and poor dentition; when endocarditis is suspected, urgent specialist review is essential; referring doctors must actively follow up referrals rather than assuming hospital a…
64y · Male·stab wound to the chest
…ded: inadequate drug testing despite Perry's drug history, failure to detect his substance abuse despite specialist parole officers' involvement, insufficient rigor in monitoring, and the previous system's reliance on ap…
35y · Female·Incised wound to neck
…mited health service engagement despite two hospital presentations with assault-related injuries without specialist referral or support; workplace colleagues witnessing violence but limited intervention pathways; and bar…
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