Deceased
John Twycross
Demographics
80y, male
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2011-05-31
Finding date
2017-03-10
Cause of death
complications of necrotising pancreatitis secondary to pancreatic biopsy (EUS)
AI-generated summary
John Twycross, an 80-year-old man with a history of hypertension, asthma, glaucoma and prior cholecystectomy, presented with acute pancreatitis in April 2011 after imaging revealed a suspected ampullary carcinoma. Following a negative PET scan in late April, he was referred for endoscopic ultrasound (EUS) with fine needle aspiration biopsy on 20 May 2011 to exclude pancreatic malignancy. The procedure caused necrotising pancreatitis, leading to rapid clinical deterioration despite emergency surgery. He died on 31 May 2011. The coroner found that informed consent was obtained by both referring surgeon Dr Smith and proceduralist Dr Tagkalidis, though documentation was inadequate. While Dr Tagkalidis did not specifically warn of death risk (quoted as 1 in 4000 fatalities), this was considered reasonable given the low incidence. The key clinical lesson is that consent documentation must be complete and contemporaneous, and both referring and procedural teams should coordinate information provision to patients, particularly in complex cancer cases.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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A 71-year-old man with myelofibrosis and prior abdominal surgery died from complications of a right hepatic artery injury during open cholecystectomy for acute cholecystitis. The operative decision was reasonable and the…
82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…
Winifred Carpenter, 82, died 11 days after a right hemicolectomy for colon cancer from peritonitis due to anastomotic leak. Critical failures occurred on discharge day (10 March 2023): clinicians did not recognize her de…
58y · Male·complications of large bowel pseudo-obstruction
Paul Desmond Smith, aged 58, died from complications of large bowel pseudo-obstruction following discharge from hospital after inadequate assessment. He had presented to the ED with lower abdominal pain and severe faecal…
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