Table 3

Significant clinical adverse events

CAERRationale
3Nosocomial COVID-19 infection in partially vaccinated patient with active COVID-19 pneumonia at time of death, although had been progressively worsening over month-long admission from inoperable aortic valve endocarditis with progressive aortic insufficiency, heart failure, splenic infarcts, vertebral osteomyelitis, renal failure.
3Documentation surrounding patient demise scarce but appears to have been dealing with progressive hypoactive delirium, renal failure, hyperkalaemia in a frail elderly polycomorbid patient, with subcutaneous lorazepam for procedural sedation for echocardiogram on day of demise.
3Deceased from COVID-19 pneumonia from nosocomial COVID-19 infection in frail unvaccinated patient with diffusely metastatic malignancy and cancer-associated pulmonary emboli.
3Deceased from Enterococcal bacteraemia in elderly frail patient, with no intravenous antibiotics for 48 hours due to inability to obtain peripheral or central venous access, though both oral and intramuscular antibiotics were initiated after 24 hours without venous access.
3Deceased from aspiration due to extensive vomiting with ileus in elderly patient with initial admission for heart failure complicated by poor pulmonary reserve from severe obesity hypoventilation syndrome—no nasogastric tube inserted as patient had not been nauseous or vomiting, and ileus had been clinically improving until day of death.
3Deceased from prosthetic joint infection with significant delay to diagnosis and antibiotic initiation in elderly patient with dementia requiring long-term care.
3Deceased from acute myocardial infarction in setting of large cardioembolic stroke from new atrial fibrillation identified on admission 4 days prior, without appropriate anticoagulation started as discussion with patient deferred.
4Deceased from bacterial meningitis after presentation of fever and delirium without clear cause of either; lumbar puncture not attempted until admission day 3; not empirically treated for meningitis/encephalitis in interim.
4Deceased from COVID-19 pneumonia from nosocomial COVID-19 infection in unvaccinated patient following admission for diagnosis of multiple myeloma and initiation of multiple myeloma.
4Deceased from COVID-19 pneumonia from nosocomial COVID-19 infection in elderly but otherwise healthy and fully immunised patient rehabilitating weeks after resolved sepsis from cholangitis.
4Deceased from recurrent aspiration resulting from hypoactive delirium following mechanical fall with head injury and nasal fracture, while recovering from congestive heart failure.
4Decreased from COVID-19 pneumonia from nosocomial COVID-19 infection in elderly, unvaccinated, significantly comorbid patient otherwise rehabilitating.
4Admitted with decreased level-of-consciousness without diagnosis on initial workup, 6-day delay until EEG showing encephalitis, 11-day delay until lumbar puncture confirming herpes simplex virus encephalitis.
4Deceased from COVID-19 pneumonia in unvaccinated patient, had been maintained on 12 L/min supplemental oxygen prior to death. Was found on nursing assessment deceased with supplemental oxygen off for an unknown duration.
  • CAER, clinical adverse event rating.