Deceased
Antonia D'Agostino
Demographics
59y, female
Date of death
2007-03-25
Finding date
2010-12-30
Cause of death
sepsis due to faecal peritonitis due to perforation of sigmoid colon complicating left oophorectomy for benign serous cystadenoma of left ovary
AI-generated summary
A 59-year-old woman died from sepsis due to faecal peritonitis following a bowel perforation during laparoscopic oophorectomy for a benign ovarian cyst. The perforation was repaired during the initial surgery, but the repair failed. The patient deteriorated at home and was readmitted. The primary issue was delay in performing emergency re-operation: the patient was scheduled for surgery at 9am but not operated until 8am the following day, by which time she was in septic shock. Expert evidence overwhelmingly supported that surgery should have been performed within 2-3 hours of admission (late Saturday evening or early Sunday morning), after brief resuscitation with fluids and antibiotics. The delay exposed the patient to preventable deterioration. While earlier surgery may not have guaranteed survival, her chances would have been significantly better in a more stable clinical state. Critical factors included failure to arrange early surgery, lack of ICU admission, and absence of a second medical opinion.
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
82y · Female·acute pyelonephritis complicating base of bladder malignancy
Joyce Binch, 82, died of acute pyelonephritis from bladder malignancy while detained under mental health legislation. She was admitted with urinary tract infection, anaemia, acute renal failure, and acute exacerbation of…
Female·Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perfor…
Two elderly women died following vaginal prolapse surgery performed by the same surgeon, Dr Onuma, with similar mechanisms: bowel perforation leading to peritonitis and sepsis. Mrs Leonard (77) underwent laparoscopic sur…
43y · Female·sepsis secondary to extensive acute peritonitis following perforation of small b…
43-year-old woman died from sepsis and necrotising fasciitis following small bowel perforation during laparoscopic tubal ligation. She was at high risk due to previous abdominal surgeries and adhesions. A 4-5mm perforati…
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