Deceased
George Kimpton
Demographics
80y, male
Coroner
Decision ofDeputy State Coroner Ryan
Date of death
2016-06-05
Finding date
2019-10-08
Cause of death
Vasodilatory shock and multi-organ failure secondary to aspiration and cardiorespiratory arrest. Significant contributing conditions: subacute pneumonia and ischaemic heart disease.
AI-generated summary
George Kimpton, aged 80, died from vasodilatory shock and multi-organ failure secondary to aspiration pneumonia five hours after cardiopulmonary arrest in hospital following colorectal cancer surgery. He had developed a post-operative ileus requiring nasogastric tube placement, which was removed on 4 June when he appeared to be recovering. That evening he developed respiratory distress, vomited copiously, aspirated gastric contents, and lost consciousness. The coroner found no fault with clinical decisions to remove the nasogastric tube or continue PCA morphine analgesia, which were supported by expert consensus. However, nursing staff failed to increase observation frequency after he showed signs of deterioration (coughing, shortness of breath), contrary to hospital policy on recognising clinical decline. This deficiency was not considered causally connected to outcome, but prompted hospital-wide teaching and implementation of improved vital sign trend visualization.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia
70-year-old Sean Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner identified multiple significant failing…
85y · Female·sepsis, with aspiration pneumonitis being an antecedent cause. Iatrogenic injury…
Lorraine Barnes, an 85-year-old woman admitted to Wollongong Private Hospital for convalescence, died from sepsis with aspiration pneumonitis following iatrogenic lung injury. She developed severe malnutrition and electr…
52y · Male·Intestinal failure/sepsis arising from venous ischemia as a result of superior m…
Patrick Thomas, a 52-year-old man, died from intestinal failure and sepsis following an accidental division of the superior mesenteric vein (SMV) during laparoscopic surgery for colon cancer at Kareena Private Hospital o…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.