158 results for “vital signs assessment”
37y · Male·Acute epiglottitis
…risoner presented with a sore throat and was assessed by a doctor who found only minor inflammation and no signs of bacterial infection, treating conservatively with analgesia. Eight hours later, after reporting difficu…
37y · Male·Cardiac failure due to sepsis due to bilateral bronchopneumonia
… M. misdiagnosed pneumonia as bronchitis despite documented lower lung crackles and blood-streaked sputum. Vital signs were not systematically assessed or recorded—blood pressure was not taken, respiratory rate was asse…
7y · Female·Group A Streptococcus (Streptococcus pyogenes) pneumonia with sepsis
…72 and 168 bpm) on 15 September 2019. NSW Ambulance protocols clearly indicated transport was required for vital signs in the 'red zone', but paramedics did not consult these protocols. The decision not to transport was…
<1y · Male·Myocarditis
…ed 1 hour 52 minutes before receiving definitive treatment due to bed unavailability. The initial triage assessment was suboptimal: complete vital signs (heart rate, respiratory rate, oxygen saturation) were not obtained…
62y · Female·Ischaemic heart disease secondary to diabetes
…She presented to her GP on 23 October 2008 with six weeks of flu-like symptoms. The GP performed limited assessment (unable to obtain blood pressure due to patient agitation) but found vital signs acceptable and made no …
11y · Male·Sepsis
… 15 June appearing critically unwell but was triaged by an incompletely trained nurse who failed to obtain vital signs. He waited 3 hours for medical review while his condition deteriorated. Critical missed opportunitie…
63y · Female·bile peritonitis as a complication from a laparoscopic cholecystectomy
…propriately by morning nursing staff. When the on-call surgeon was contacted by evening nursing staff with vital signs and ECG findings showing sinus tachycardia, she ordered only IV fluids and analgesia without clinica…
4y · Male·Haemophilus influenzae septicaemia with superimposed respiratory tract infection
…mia with respiratory tract infection and bilateral pleural effusions. The NT Health review identified that vital signs fell outside normal ranges (meeting ATS category 3), repeat vitals were not documented before discha…
31y · Male·Undetermined
…lamphetamine intoxication, physical/psychological stress, sedation). Paramedics failed to conduct adequate vital signs assessment, hands-on examination, or continuous monitoring pre-arrest. They mistook his rapid declin…
62y · Female·Acute bacterial peritonitis and pneumonia
…tation for superannuation funding, undermining credibility. Post-operative failures: Despite deteriorating vital signs (oxygen saturation and blood pressure) and persistent vomiting on discharge day (26 Feb), she was in…
8y · Male·bacterial meningitis that had not been diagnosed by a number of clinicians who h…
…ate differential diagnosis (anchoring to gastroenteritis despite absent diarrhoea), overreliance on normal vital signs while ignoring toxicity signs (lethargy, fever, headache, persistent vomiting, pallor), and failure …
1y · Male·Cerebral anoxia caused by cardiac arrest caused by bronchiolitis and bronchopneu…
…st. The coroner found no evidence of pneumonia on 16 July examination and accepted that Dr M.'s clinical assessment met acceptable standards, though documentation of findings was inadequate. The coroner endorsed the view…
86y · Female·Cardiogenic shock
…t misinterpreted because the device printout lacked reference ranges. Critical failures included: abnormal vital signs not escalated to medical staff, no documented differential diagnosis or risk stratification, no clea…
13y · Male·Peritonitis secondary to ruptured gangrenous acute appendicitis
…quate history-taking (not documenting pain severity or functional impact), incomplete examination (cursory vital signs, no pulse recorded, no stethoscope used), failure to investigate despite deterioration over several …
1y · Male·Septicaemia due to Streptococcal (Beta Haemolytic Group A) infection
…a 17-month-old boy, presented to the Emergency Department with fever, lethargy, vomiting, and tachycardia. Vital signs showed heart rate 173 bpm (red zone) and fever 38.9°C. Dr T. diagnosed viral illness (possibly Fifth…
21y · Male·Hypoxic brain injury in the setting of drug toxicity
… during 75-minute placement in holding cell where deterioration was not appreciated, and failure to assess vital signs when transferred to observation cell where he was left prone. Communication breakdowns between corre…
55y · Male·Complications of alcohol use disorder
…l care included: inadequate recording of observation frequency by the medical officer; failure to document vital signs appropriately; insufficient monitoring (only two sets of vital observations in 10 hours overnight); …
30y · Male·methadone toxicity
…tions including methadone, benzodiazepines, and antipsychotics. Critical gaps in care included: inadequate vital sign monitoring (only 8 occasions during 6-day admission), no documented observations after Acuphase admin…
<1y · Male·cardiac arrhythmia associated with surgically corrected congenital heart disease
… medical emergencies. The sole registered nurse, Gail Griffin, failed to contact a doctor despite alarming vital signs, instead advising parents to take the baby home with minimal monitoring instructions. The baby deter…
58y · Male·Pneumonia and urosepsis
…His indwelling catheter was poorly managed, causing urethral trauma and erosion. Staff failed to recognise signs of clinical deterioration including respiratory decline, fever, and behavioural changes indicative of pain…
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