64 results for “x-ray examination”
89y · Female·Pulmonary embolism due to deep venous thrombosis
…ay delay. The coroner found Dr D.-Mustapha's initial ED assessment was inadequate; she failed to order hip X-rays despite a clear history of fall with hip pain, mobility loss, and inability to weight bear. The coroner w…
63y · Male·Metastatic carcinoma of the lung
…o see the doctor on 23 March 2008 was addressed only by telephone consultation rather than face-to-face examination, and no chest X-ray was ordered despite persistent respiratory symptoms and antibiotic relapse. While e…
29y · Male·Florid myocarditis
…ditis with pleural effusion. Expert evidence established that appropriate investigation with ECG and chest X-ray would likely have detected the condition and led to hospital admission. Key clinical lessons: syncope is c…
69y · Female·faecal peritonitis due to small bowel obstruction and perforation due to periton…
…t with abdominal pain and vomiting. The doctor did not take adequate history, perform thorough physical examination, or order basic investigations including blood tests or abdominal X-ray. She was discharged after 2 hou…
6y · Male·pneumonia complicating influenza A (H1N1) infection with secondary streptococcal…
… inadequate handover between Dr R. and Dr C. on 15 September 2010 resulting in discharge with pneumonia on X-ray; and critically, Dr I.'s failure on 16 September 2010 to diagnose compensated septic shock despite documen…
48y · Male·Pulmonary fibrosis associated with scoliosis
…ith antibiotics. On 21 September, he had persistent chest crepitations despite antibiotic therapy; a chest X-ray was arranged but results are not documented. On 26 September, examination appeared improved with no respir…
38y · Male·metastatic lung carcinoma
…ht loss, poor appetite, and a persistent cough. Despite multiple medical consultations and investigations (X-rays, CT scans), imaging focused on musculoskeletal pathology and missed the underlying malignancy. When sent …
0y · Male·unascertained; possibly asphyxiation related to sleeping position
…rrangements. At prior hospital admission on 17 September 2010 for fever and reported haematemesis, a chest X-ray revealed healing rib and humerus fractures suggestive of inflicted injury, but these were not recognised b…
7y · Female·streptococcus pneumoniae sepsis complicating retropharyngeal abscess
…ractitioner with no child abuse training examined both children and found no obvious injuries. Critically, X-rays were not performed despite allegations of shaking; these would have revealed rib and leg fractures, confi…
38y · Female·peritonitis with septic shock secondary to perforation of the gastrointestinal t…
A 38-year-old woman in persistent vegetative state following anoxic encephalopathy from anaphylaxis during surgery died from peritonitis caused by perforation at the gastrostomy stoma site. The perforation likely occurre…
33y · Male·hypoxic respiratory failure following right pneumonectomy for treatment of sever…
…tical clinical lessons include: the importance of face-to-face pre-discharge TB screening with physical examination rather than telephone assessments; reviewing radiologist reports alongside clinician interpretation (di…
86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall
…equately assess his back pain. Rib fractures went undiagnosed despite being the critical injury. The chest x-ray had low sensitivity for fractures. Additionally, an ED clinician erroneously prescribed 100mg therapeutic …
91y · Male·The combined effects of chest injuries and old age
…coroner found discharge was not unreasonable given that clinicians could not detect acute fractures on the x-rays reviewed. However, the key failure was lack of a policy to review delayed specialist radiology reports an…
1y · Female·acute myocardial infarction secondary to Kawasaki's Disease
… months of age. Initial clinical assessment by multiple doctors found no obvious cardiac abnormality on examination. Chest x-rays were reviewed by the treating doctor (non-radiologist) who noted pneumonia and possible c…
70y · Female·Cardiac arrest caused by a combination of gastric haemorrhage and pneumonia exac…
Mrs Kathleen Anne Conlan, 70, died from cardiac arrest caused by gastric haemorrhage and pneumonia on a background of coronary artery disease. She presented with severe epigastric pain and was appropriately admitted for …
23y · Male·aspiration of blood due to stab wound to trachea
…estigation. Patient was intoxicated, uncooperative, making assessment difficult. Discharged after brief examination. Patient represented hours later with back pain; intern examined him but did not reassess neck wound. H…
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…
57y · Male·Bronchopneumonia complicating metastatic and locally advanced primary adenocarci…
A 57-year-old male prisoner died from bronchopneumonia complicating metastatic lung adenocarcinoma. He was diagnosed with stage IV lung cancer in February 2016 while incarcerated and opted for palliative care, declining …
58y · Male·salt water drowning following air embolism due to ascent barotrauma
…and possible dehydration. The coroner found this death preventable, emphasising that a pre-dive medical examination by a practitioner trained in diving medicine would have identified pleural adhesions on chest X-ray and…
62y · Male·Aspiration pneumonia complicating epilepsy in the setting of Down syndrome
Richard Watson, a 62-year-old man with Down syndrome, epilepsy, dementia and C1 partial quadriplegia, died from aspiration pneumonia at Austin Hospital. He had recurrent admissions over six months for pneumonia, asthma a…
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