52 results for “speech delay”
51y · Female·Aspiration in the setting of end stage down syndrome
…ividualised mealtime assistance plan despite her progressive dysphagia and increasing seizures; infrequent speech pathology reviews despite neurologist documentation of worsening swallow function in June 2018; and undate…
72y · Male·Choking on a food bolus
…lack of training in safe feeding techniques for residents with swallowing difficulties, absence of regular speech pathology assessments, and inadequate emergency response skills. Key clinical lessons: aged care facilitie…
9y · Female·suicide by hanging
…riginal Placement Principle was not followed: family members offered to care for her, but assessments were delayed or stalled for years on bureaucratic grounds. She had experienced significant trauma including parental …
83y · Male·Aspiration pneumonia
…mined by his GP who diagnosed a chest infection and opted for conservative management in the nursing home. Speech pathology assessment later that day identified severe dysphagia and aspiration risk, recommending pureed d…
42y · Female·Hypoxic brain injury due to choking on food, with Cornelia de Lange Syndrome con…
…critical system failures: incomplete dysphagia assessment without follow-up, lack of collaboration between speech pathology and dietetics, inadequate support worker training on soft diet standards, and NDIS structural de…
81y · Female·Aspiration pneumonia in an elderly lady
…g repeated admissions for the same condition. She had been assessed as 'very high risk of aspiration' by a speech pathologist in January 2019 but continued to receive inadequate mealtime assistance at her group home. A m…
65y · Female·choking on a tangerine
…spital. She had documented choking risk and clear recommendations for supervised eating and soft diet from speech pathology. Critical failures included inadequate communication of dietary restrictions during handover fro…
59y · Female·Global cerebral oedema due to hypoxic cerebral ischaemia following cardiac arres…
59-year-old woman admitted with newly diagnosed grade 4 glioblastoma underwent surgery 16 days later after delays during consultant's planned leave. Post-operative complications included ischaemic stroke confirmed on im…
42y · Female·Hypoxic brain injury due to choking on food, in a person with Cornelia de Lange …
…priate and Ms Lowry responded correctly to the emergency, systemic failures were identified: Ms Campbell's speech pathology assessment was incomplete and not followed up; Ms Rees' meal plan was not properly communicated …
50y · Male·Hypoxic-ischaemic encephalopathy secondary to choking on food bolus
…r appropriately called 000 and commenced CPR, but communication difficulties with the emergency dispatcher delayed recognition of cardiac arrest. Paramedics initially failed to visualise and remove the airway obstructio…
60y · Male·burn wounds and the consequences thereof
…ations for his behaviour and not scheduling him for involuntary assessment despite concerning signs: rapid speech, paranoia, threats of violence, financial delusions, and resumed alcohol use. The GP retrospectively ackno…
52y · Male·Aspiration pneumonia in a man with end stage Huntington's disease
…alist residential care, died of aspiration pneumonia. He had documented swallowing difficulties managed by speech pathology and dietetics with a mealtime management plan reassessed multiple times in 2024. In late August,…
4y · Male·drowning
Tallen Pitt, a 4-year-old boy with speech delay, drowned in an unfenced 1.25-metre deep backyard swimming pool on 7 November 2020. The pool was purc…
90y · Female·Infected sacral ulcer and fluid imbalances in the context of dementia
…tified failures in communication with her Enduring Power of Attorney (daughter), inadequate involvement of speech pathology or dietetics for her swallowing/nutrition concerns, and unclear clinical decision-making about w…
23y · Male·combined drug toxicity (methadone, clozapine, quetiapine, diazepam, chlorpromazi…
…aking him vulnerable to overdose; and nursing staff failed to escalate concerning signs (sedation, slurred speech, unsteady gait) until too late. Preventable factors include inadequate inter-service communication, lack o…
69y · Female·Respiratory obstruction by aspirated food (Brussels sprout, chicken and carrots)…
… coroner identified several deficiencies: inadequate staffing (one carer supervising meals alone), lack of speech pathology assessment despite risk factors, failure to use appropriate choking management techniques (later…
29y · Male·Sudden Unexpected Death in Epilepsy (SUDEP)
…iting expedited neurological review scheduled for January 2024 when he died. The coroner noted an apparent delay in accessing specialist neurological care but did not find the death preventable, recognizing that anti-ep…
39y · Male·Effects of fire (self-immolation)
… was triaged as Category 4 despite appearing well and driving himself. Mental Health Triage assessment was delayed due to resource constraints. Critically, William was permitted to leave the ED unsupervised to smoke a c…
25y · Female·mixed drug toxicity
…h. After calling a counsellor from Rural Alive and Well reporting overdose and suicidal intent, a critical delay occurred: the police dispatch operator failed to simultaneously request an ambulance despite credible info…
61y · Male·Creutzfeldt-Jakob disease
…e subject to a Level 2 Inpatient Treatment Order. He presented with rapidly progressive cognitive decline, speech difficulties, and motor dysfunction from November 2017 onwards. Initial assessment by his general practiti…
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