Coronial
VICother

Finding into death of Nilofer Nezami

Deceased

Nilofer Nezami

Demographics

38y, female

Coroner

Deputy State Coroner Caitlin English

Date of death

2019-01-07

Finding date

2022-03-21

Cause of death

Unascertained

AI-generated summary

Nilofer Nezami, a 38-year-old Victorian resident, died on 7 January 2019 following cosmetic surgery in Iran. She underwent multiple procedures including eye, breast, arm and abdominal surgery. Post-operatively, she developed symptoms including cold hands, pain and altered consciousness, progressing to cardiac arrest. A local hospital reported embolism as cause of death. Australian post-mortem examination could not establish definitive cause due to prior overseas autopsy, embalming, and incomplete medical records. Possible causes identified included cardiac arrhythmia, metabolic derangement, or pulmonary embolism following recent surgery. The case highlights risks of medical tourism including variable standards of care, limited follow-up, and difficulty investigating overseas deaths. Clinical lessons include the need for pre-operative screening, awareness of thromboembolism risk post-operatively, and consideration of performing multiple procedures on same day.

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Specialties

plastic and reconstructive surgeryanaesthesiaemergency medicine

Error types

systemprocedural

Drugs involved

morphinecodeinemidazolamparacetamolatropineondansetronlidocaineenoxaparin

Clinical conditions

cardiac arrhythmiapulmonary embolismischaemic hepatitishypovolaemiasepsis

Procedures

cosmetic surgeryeyelid surgerybreast surgeryliposuctionabdominal contouringgeneral anaesthesiaendoscopy

Contributing factors

  • Recent cosmetic surgery
  • Multiple surgical procedures performed in close proximity
  • Possible cardiac rhythm disturbance
  • Possible metabolic and biochemical derangements post-operatively
  • Possible pulmonary thromboembolism
  • Potential ischaemic hepatitis
  • Inadequate pre-operative screening
  • Limited post-operative monitoring
  • Incomplete medical documentation

Coroner's recommendations

  1. The Victorian Chief Health Officer should publish an alert/advisory regarding the risks of medical tourism, including advice that the standard and quality of medical care provided in other countries may not be of the same standard as that provided in Australia.
Full text

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