Coronial
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Coroner's Finding: Cheesman, Trevor Allan

Deceased

Trevor Allan Cheesman

Demographics

70y, male

Date of death

2021-07-31

Finding date

2025-07-03

Cause of death

complications arising from craniofacial resection and orbital exenteration for right sinonasal adenocarcinoma

AI-generated summary

A 70-year-old man died following complex craniofacial resection and orbital exenteration for right sinonasal adenocarcinoma. Multiple surgical complications occurred including carotid artery injury, cerebral infarction, CSF leak, and infection. He developed delirium postoperatively necessitating Mental Health Act orders. The coroner found the ITOs were appropriately imposed and there was a delay in the first ITO review due to notification system failures, subsequently rectified. No failings by medical staff contributed to death. The prognosis was guarded given extensive surgery, complications, and comorbidities. The death resulted from surgical complications in the context of high-risk surgery for an aggressive malignancy.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

neurosurgeryENT surgeryplastic and reconstructive surgeryintensive carepsychiatry

Error types

system

Drugs involved

olanzapine

Clinical conditions

sinonasal adenocarcinomadeliriumcerebral infarctionCSF leakcarotid artery injurypneumocephalusescherichia coli infectionhemiplegiachronic obstructive pulmonary diseasegastro-oesophageal reflux disease

Procedures

craniofacial resectionorbital exenterationfree flap reconstructionfascial leg graftlumbar drain insertionendoscopic repair of skull base defectsurgical tracheostomyCT angiographyperiorbital soft tissue aspiration

Contributing factors

  • intraoperative carotid artery injury
  • cerebral infarction
  • CSF leak
  • bacterial infection (Escherichia coli)
  • pneumocephalus
  • periorbital soft tissue infection
  • pre-existing comorbidities (COPD, prostatic hypertrophy, GORD, androgen deficiency)
  • extensive surgical complications
  • delirium postoperatively
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