26 results for “ultrasound examination”
0y · Male·Hypoxic-ischemic encephalopathy and massive subgaleal haemorrhage, both associat…
…successful vacuum extraction. Clinical failures included: inadequate determination of fetal position (no ultrasound used despite disagreement between clinicians), incorrect placement of vacuum cup, unreasonably delayed c…
Philip Byrne: pulmonary thromboembolism due to right calf deep vein thrombosis; …
…bosis (DVT). Mr Byrne presented with right calf pain in February 2012; two GPs excluded DVT on clinical examination alone without ordering ultrasound despite his history of previous DVT. Mrs Weaver presented with left c…
72y · Female·multiple bilateral pulmonary infarcts caused by multiple pulmonary thromboemboli…
… bandaging and aspirin by general practitioners. On 18 June 2015, despite ongoing leg tenderness, duplex ultrasound investigation was not ordered to exclude deep vein thrombosis, despite multiple significant risk factors…
25y · Female·ruptured splenic artery aneurysm with haemorrhage and internal blood loss
…gardless of initial stability; (2) consultant involvement was absent until final collapse; (3) a planned ultrasound examination was not carried out despite clinical deterioration; (4) the 'double rupture phenomenon' with…
0y · Male·subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour
…ns include: fetal position must be definitively established before instrumental delivery using clinical examination and ultrasound if uncertain; unaccredited registrars require direct supervisor presence; slow labour pr…
0y · Female·Intrapartum hypoxia due to breech delivery with head entrapment and associated c…
… of vaginal breech delivery, the urgency of hospital attendance once labour started, and the accuracy of ultrasound imaging. While Dr S.'s advice and clinical management were deemed adequate, the family's failure to reco…
51y · Female·Ischaemic heart disease
…ge requiring prosthetic replacement. She presented with an infected breast lesion but resisted physical examination due to severe aversion to touch during acute psychiatric crisis. Cardiology input was sought but did no…
23y · Female·Arrhythmia of unknown aetiology
TV died on 1 November 2016 from arrhythmia of unknown aetiology whilst in MHICU at Prince of Wales Hospital. She was a 23-year-old with severe bipolar disorder, mild intellectual disability and borderline personality tra…
45y · Male·Intra Abdominal Haemorrhage Associated with Metastatic Carcinoma of the Oesophag…
… presented with upper abdominal pain and jaundice. Dr G. appropriately investigated with blood tests and ultrasound, becoming concerned by results and urgently referring him to Fremantle Hospital on 28 November. At hospi…
4y · Male·acute suppurative peritonitis following rupture of an inflamed vermiform appendi…
…cy with vomiting and fever. Appendicitis was considered as a primary diagnosis from admission. Clinical examination was challenging due to communication difficulties, but findings were initially concerning then appeared…
72y · Male·acute gangrene of colon with probable perforation along with bowel obstruction a…
Giovanni Bertoncini, a 72-year-old man with diabetes and cardiac disease, presented to Sir Charles Gairdner Hospital on Christmas Day 2002 with acute abdominal pain and vomiting. Over two days, his condition deteriorated…
0y · Female·Hypoxia resulting from primary idiopathic pulmonary hypertension of the newborn …
…npredictable and not preventable. The inquest focused on systemic issues regarding perinatal postmortem examinations in NSW coronial cases. The initial autopsy raised unfounded concerns about pethidine given to the moth…
0y · Male·Perinatal hypoxia
…iple presentations during pregnancy with reduced foetal movements, and investigations including CTGs and ultrasounds were performed. Clinical lessons include the importance of recognising cumulative significance of repea…
68y · Female·Multi-organ failure associated with septic shock following duodenal perforation …
Athenia Hana Walden, 68, died from multi-organ failure and septic shock following duodenal perforation during laparoscopic surgery at Swan District Hospital on 8 May 2008. Surgery was performed to remove her gallbladder,…
10y · Male·Unascertained - sudden and unexpected death; evidence did not allow determinatio…
…itive diagnosis was established. An EEG was recommended but not completed before his death. Post-mortem examination revealed subtle cardiac inflammation and minor brain findings but no definitive cause. Critical learnin…
29y · Male·severe neonatal encephalopathy, post palliative care; possible underlying cause:…
A 29-day-old neonate died from severe neonatal encephalopathy following birth asphyxia. The infant was born after prolonged induction and protracted second-stage labour at Lyell McEwin Hospital, followed by instrumental …
74y · Male·disseminated carcinoma (widespread cancer); specifically haemorrhage into right …
Ronald Smallwood, a 74-year-old man with chronic paranoid schizophrenia and renal cancer, died in hospital from disseminated carcinoma. The key clinical lesson relates to institutional knowledge rather than direct patien…
62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…
A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…
31y · Female·Ruptured splenic artery aneurysm with extensive retroperitoneal and intraperiton…
Michelle Johnson, a 31-year-old pregnant woman at 32 weeks gestation, presented to the Royal Women's Hospital with sudden-onset severe left-sided abdominal pain and hypotension on 21 March 2010. She was assessed by regis…
0y · Male·hypoxic ischaemic encephalopathy due to intrapartum asphyxia
Bodhi Leo Searle, aged 36 hours, died from hypoxic ischaemic encephalopathy due to intrapartum asphyxia. He was born to a woman in low-risk labour managed initially by independent midwife Stephanie Geyer. When labour did…
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