Deceased
Emily Ruth Leonard and Glenys Anne Hillman
Demographics
female
Date of death
2008-11-25 and 2009-07-18
Finding date
2011-08-05
Cause of death
Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perforation of the colon during a laparoscopic gynaecological procedure. Glenys Anne Hillman: hypoxic ischaemic brain injury due to an intracerebral and subdural haemorrhage as a consequence of anticoagulation given to treat a left subclavian vein thrombosis and pulmonary thromboemboli, and peritonitis following perforation of the small bowel during surgery for vaginal prolapse.
AI-generated summary
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 surgery on 30 October 2008; a colon perforation from diathermy-induced injury was not recognized intraoperatively and only became apparent 6 days post-discharge, resulting in multi-organ failure and death. Mrs Hillman (67) underwent open surgery on 28 May 2009; a small bowel perforation was identified and repaired intraoperatively, but the repair failed within 24 hours, leading to contamination, aspiration pneumonia, ARDS, necrotising fasciitis, intracranial bleeding during anticoagulation, and death. Both surgeries involved extensive adhesiolysis. Expert evidence suggested vaginal approaches carried lower bowel injury risk. Key clinical lessons: careful consideration of surgical approach in patients with extensive adhesions; heightened vigilance for early peritonitis signs post-complex abdominal surgery; appropriate drain placement; the importance of formal accreditation and examinations for complex gynaecological surgery rather than reliance on reputation and self-certification.
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
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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…
59y · Female·sepsis due to faecal peritonitis due to perforation of sigmoid colon complicatin…
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 re…
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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