Deceased
Oi Fong Chan
Demographics
77y, female
Date of death
2006-12-09
Finding date
2010-11-05
Cause of death
Intracranial haemorrhage suffered during the course of neurosurgery
AI-generated summary
Oi Fong Chan, a 77-year-old woman, underwent endoscopic trans-nasal pituitary surgery at Concord Hospital on 8 December 2006 to remove a benign pituitary adenoma. During the operation, the surgical team inadvertently encountered an aberrant (abnormally positioned) blood vessel and the surgical field began bleeding profusely. Despite appropriate use of multiple haemostatic techniques including packing, surgicel, thrombin, and gelfoam, the bleeding continued on the other side of the packing, causing severe intracranial and intraventricular haemorrhage. Mrs Chan died on 9 December 2006 from raised intracranial pressure and brain stem compression. Investigation revealed no surgical error or misnavigation—the complication resulted from natural anatomical variation: an aberrant vessel and the patient's slightly lower brain position. The coroner found this an unavoidable tragedy. The surgical team demonstrated appropriate skill and management. Recommendations addressed surgical teamwork: formal pre-operative team briefings and introductions by name and role, with WHO checklist adaptation for NSW.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Clinical conditions
74y · Male·Acute myocardial infarction complicated by multiple organ failure
Ronald William Beaumont, 74, died from acute myocardial infarction complicated by multiple organ failure following a second shoulder washout procedure. Key clinical lessons: (1) Despite inadvertent withholding of dual an…
78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …
A 78-year-old woman died from hypoxic ischaemic encephalopathy following an acute post-surgical arterial bleed that obstructed her airway after hemithyroidectomy. The bleeding complication occurred when she coughed after…
62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (su…
A 62-year-old man died from intraoperative haemorrhage during surgery for a renal tumour initially diagnosed as benign anastomosing haemangioma on biopsy but found at autopsy to be metastatic clear cell renal cell carcin…
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. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. 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 —