1y · Female·Dilated cardiomyopathy
…ot occur was critical. Key failures: blood pressure was never recorded despite tachycardia (170 bpm) and tachypnoea (60/min) beyond 99th centile; no consultant paediatrician review despite admission under their care; MET…
58y · Male·metastatic carcinoma of the pancreas
…itted with psychosis in December 2016. On 5 January 2017, while awaiting ECT, an anaesthetist identified tachypnoea, tachycardia and wheezy breathing. Investigations revealed untreatable pancreatic cancer, leading to pal…
60y · Female·Non-operative management of ruptured oesophagus (palliated)
…ed mild tenderness that improved. She deteriorated acutely on 20 March with pain, distress, tachycardia, tachypnoea and hypoxia, and was found to have a ruptured oesophagus. After discussion with parents, non-operative p…
17y · Male·Diabetic ketoacidosis
…y and inability to move. Paramedics attended on 27 May evening and found him with tachycardia (120 bpm), tachypnoea (40 bpm), hypothermia and signs of dehydration, but attributed his presentation to anxiety and upper res…
56y · Male·Complications of a small bowel obstruction
…tially diagnosed with aspiration pneumonia and myocardial infarction, but subsequently deteriorated with tachypnoea and tachycardia. Post-mortem imaging revealed a small bowel obstruction with air-fluid levels but no ide…
63y · Male·Aspiration pneumonia in a man with trisomy 21, Alzheimer's dementia and other me…
…iving specialist disability accommodation. He presented to hospital on 8 September 2024 with hypoxia and tachypnoea, was started on antibiotics and non-invasive ventilation, but his condition deteriorated over several da…
0y · Male·cardiac arrhythmia associated with surgically corrected congenital heart disease
…rrhythmia. On 13 January 2007, he presented to Mullewa Hospital with fever, tachycardia (pulse 192), and tachypnoea (respiratory rate 88), all constituting medical emergencies. The sole registered nurse, Gail Griffin, fa…
61y · Male·Complications of metastatic adenocarcinoma
…ions). He was diagnosed in February 2022 after presenting to Wagga Wagga Base Hospital with hypotension, tachypnoea, weight loss, and pleural effusion. Following consultation with oncology and palliative care, he decline…
83y · Male·Pneumonia
…es. On 9 February 2025, nursing staff noted signs of acute deterioration (pallor, poor capillary refill, tachypnoea, altered responsiveness, difficulty swallowing) and appropriately arranged hospital transfer. He was adm…
11y · Female·Acute Staphylococcal Septicaemia due to suppurative arthritis of the left ankle
…njury. She presented three times over three days with escalating signs of infection (fever, tachycardia, tachypnoea, swollen warm ankle). On her third presentation to the Emergency Department at 11pm, a nurse recognised …
69y · Female·Aspiration pneumonia in the setting of cerebral palsy and PEG tube feeding
…Despite treatment with intravenous antibiotics, her condition deteriorated over nine days with worsening tachypnoea and increasing oxygen requirements. Following consultation with her family, her care was transitioned to…
85y · Male·pneumonia
… persisted despite oral antibiotic therapy. On 28 January 2016, he was found with altered mental status, tachypnoea, and reduced Glasgow Coma Scale (6/15), with chest X-ray showing left-sided consolidation. He was transf…
69y · Male·Perforated bowel/septicaemia as a result of diverticulitis
…ra-abdominal pathology (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 …
66y · Male·inanition and probable respiratory tract infection complicating Alzheimer's deme…
Peter Joseph Hammond, aged 66, died from inanition and probable respiratory tract infection complicating advanced Alzheimer's dementia. He was admitted to the Acute Older Persons Mental Health Unit at Flinders Medical Ce…
62y · Female·Aspiration pneumonia in the setting of refractory focal status epilepticus
…-epileptic medication, experienced progressive deterioration with reduced consciousness, hypoxaemia, and tachypnoea. The coroner found treatment at Northern Hospital and by CareChoice was reasonable and appropriate. The …
71y · Female·multiple pulmonary thromboemboli and deep vein thrombosis
71-year-old woman presented to ED with signs of circulatory failure (hypotension, tachycardia, tachypnoea, hypoxia) and progressive leg pain/swelling over one week. ECG showed S1Q3T3 pattern consistent with pul…
38y · Male·Urosepsis
…strict Nursing Service, the catheter began bypassing. He deteriorated rapidly that afternoon with fever, tachypnoea and hypoxia, presenting to hospital in septic shock requiring intensive care. Despite aggressive treatme…
36y · Female·Complications of pneumonia and pulmonary emphysema with bullae formation; respir…
…acquired pneumonia and sepsis. She had multiple 'red flag' indicators of severity including hypotension, tachypnoea, and hypoxia. Critical failures included: inadequate appreciation of sepsis severity; failure to escalat…
31y · Female·urosepsis due to acute pyelonephritis
…ed the same afternoon with fever, moaning and dark urine. Despite vital sign abnormalities (tachycardia, tachypnoea, hypotension) and elevated inflammatory markers, she was diagnosed with lower UTI rather than pyelonephr…
2y · Female·Chronic organic brain damage as a consequence of Murray Valley encephalitis
…She presented to hospital with vomiting, diarrhoea, increased seizures, and signs of shock (tachycardia, tachypnoea, fever, peripheral shutdown). Despite emergency care, she died 3 hours after arrival. The autopsy confir…
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