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WAhospital2018-06-14

Inquest into the Death of Anne RZEPCZYNSKI

59y · Female·complications of intra-abdominal sepsis, including multi-organ failure and bowel…

59-year-old woman died from intra-abdominal sepsis, multi-organ failure and bowel perforation following median hepatectomy for cholangiocarcinoma. Key clinical issues included: surgical delays of 20 days between stent in…

general surgeryintensive carediagnosticdelayantibiotics
NSWhospital2018-06-06

Inquest into the death of Dr Malay Rana

27y · Male·Loss of airway control and blockage due to aspiration from complications of a sm…

Dr Malay Rana, a 27-year-old physician with cystic fibrosis, died from aspiration and airway blockage secondary to a small bowel obstruction whilst under dual respiratory-surgical care at Westmead Hospital. Critical clin…

respiratory medicinegeneral surgerycommunicationdiagnosticfentanyl
TAShospital2018-05-30

Coroner's Finding: Forward, Trudi Maree

53y · Female·sepsis and multiple organ failure attributable to infarction/necrosis of small b…

A 53-year-old woman with Type II diabetes, obesity, and Korsakoff dementia presented with acute severe abdominal pain from superior mesenteric artery (SMA) thrombosis at 3:00 AM on 19 August. Despite elevated lactate, me…

emergency medicinegeneral surgerydiagnosticdelay
NSWhospital2018-04-26

Inquest into the death of Margaret Ann Pegum

67y · Female·Sepsis as a result of gastric perforation

Margaret Pegum, aged 67, died from sepsis following gastric perforation after an intragastric balloon (IGB) procedure for weight loss. She had undergone fundoplication for hiatus hernia in 2012. Despite prior gastric sur…

gastroenterologybariatric surgerydiagnosticcommunication
QLDhospital2017-06-22

Mead, Gwendoline

73y · Female·Multiple organ failure due to or as a consequence of sepsis due to or as a conse…

73-year-old woman died 12 days after elective colorectal surgery for synchronous caecal and rectal tumours. Post-operatively, she developed persistent low urine output and intermittent hypotension managed with repeated f…

colorectal surgerygeneral surgerydiagnosticdelay5-fluorouracil
TAShospital2017-06-16

Coroner's Finding: Baldock, Andrea Eileen

46y · Female·combined effects of aspiration pneumonia due to gastroparesis following sleeve g…

A 46-year-old woman died from aspiration pneumonia due to gastroparesis following sleeve gastrectomy, complicated by ischaemic heart disease. Post-operative recovery was beset with persistent vomiting, dehydration, and e…

general surgerygastroenterologysystemdelay
TAShospital2017-05-19

Coroner's Finding: Smith, James Maurice

38y · Male·haemopericardium (pericardial tamponade) due to aortic dissection

James Maurice Smith, 38-year-old male, died from haemopericardium due to aortic dissection. He presented to ED on 9 June 2015 with severe back and abdominal pain, elevated lactate, and neurological symptoms suggesting va…

emergency medicinegeneral surgerydiagnosticcommunicationondansetron
NThospital2017-03-30

Inquest into the death of Irene Magriplis

75y · Female·septic complications following surgical resection of duodenal ampullary adenoma

A 75-year-old woman died of sepsis from bile leaking into her abdomen after elective surgery to remove a pre-malignant tumour adjacent to the bile duct. The coroner found multiple preventable failures: inadequate pre-ope…

general surgeryanaesthesiadiagnosticprocedural
TAShospital2016-12-16

Coroner's Finding: Harrison, Jason Keith

34y · Male·sepsis due to extensive small bowel infarct caused by bowel incarceration within…

Jason Keith Harrison, aged 34, died from sepsis due to extensive small bowel infarction caused by bowel incarceration within a congenital mesenteric hernia. He presented to West Coast District Hospital with epigastric pa…

emergency medicinegeneral practicediagnosticdelay
VIChospital2016-09-15

Finding into death of Bernas Hasibuan

50y · Male·gastrointestinal haemorrhage; haemorrhage from cystic artery post laparoscopic c…

A 50-year-old man died from gastrointestinal haemorrhage involving both a cystic artery and duodenal defect following laparoscopic cholecystectomy. Over five days post-surgery, he developed repeated episodes of hypotensi…

general surgeryintensive carediagnosticcommunication
VIChospital2016-06-24

Finding into death of Graeme John Jennings

65y · Male·staphylococcal sepsis (secondary to Staphylococcus aureus infection seeding rect…

A 65-year-old man presented with quad bike accident injuries and had markedly elevated inflammatory markers (CRP 329–556, WCC 12.3–18) during his first hospital admission. These were suggestive of developing infection, p…

general surgeryemergency medicinediagnosticcommunicationindocid
SAhospital2016-05-25

Coroner's Finding: PALTRIDGE Mellanie Joanne

25y · Female·ruptured splenic artery aneurysm with haemorrhage and internal blood loss

A 25-year-old pregnant woman (23 weeks) presented to hospital with sudden left upper quadrant abdominal pain and loss of consciousness. Clinical assessment identified renal colic and gallstones as likely diagnoses. She r…

obstetricsemergency medicinediagnosticdelayparacetamol
WAhospital2016-05-18

Inquest into the Death of Janice May SAULYS

69y · Female·multi-organ failure due to sepsis of unknown origin

A 69-year-old woman with diabetes, cardiac disease, and vulnerable kidneys died from multi-organ failure due to sepsis of unknown origin. She presented to a rural hospital on 28 June 2012 with vomiting, dehydration, and …

emergency medicinegeneral practicesystemdelay
VIChospital2016-05-12

Finding into death of Kevin Stanley Margetts

63y · Male·Bowel obstruction

A 63-year-old man with severe intellectual disability, quadriplegia, and blindness died from bowel obstruction with sepsis. On 5 September 2015, carers noted cough and eating difficulties. A locum doctor visited, noted h…

general practiceemergency medicinedelaysodium citrate enema
TAShospital2015-11-27

Coroner's Finding: McManus, Pamela

75y · Female·large volume aspiration following right hemicolectomy for adenocarcinoma of the …

A 75-year-old woman with a 20-month history of iron deficiency anaemia was not investigated for its cause by her general practitioner despite clear clinical signs of deterioration. The coroner found this fell 'grossly sh…

general practicegeneral surgerydiagnosticcommunication
QLDhospital2015-05-26

SM - Non-inquest findings

32y · Male·Pulmonary embolism originating from deep vein thrombosis in right calf

A 32-year-old man died from pulmonary embolism six days after emergency appendectomy for perforated appendicitis. VTE prophylaxis was appropriately prescribed. However, the clinical team failed to investigate persistent …

general surgeryanaesthesiadiagnosticcommunicationheparin
SAhospital2015-03-02

Coroner's Finding: PALTRIDGE Mellanie Joanne - Ruling (2)

25y · Female·ruptured splenic artery aneurysm

A 25-year-old pregnant woman (23 weeks gestation) presenting with collapse and severe abdominal pain was not definitively diagnosed with a ruptured splenic artery aneurysm despite examination by multiple medical practiti…

emergency medicineobstetricsdiagnosticdelay
VIChospital2014-11-28

Finding into death of June Olive Pegg

80y · Female·peritonitis due to sigmoid resection margin leak following extended right hemico…

June Olive Pegg, 80, died from peritonitis following anastomotic leak after extended right hemicolectomy for colonic cancer. Critical delays in diagnosis occurred: a PET scan in May 2010 showed a colonic mass, but respir…

colorectal surgerygeneral surgerydiagnosticdelayfurosemide
VIChospital2014-08-29

Finding into death of Noella Rae Clohesy

62y · Female·Multi-organ failure due to lacerated abdominal aorta complicating laparoscopic b…

A 62-year-old woman died from multi-organ failure caused by a lacerated abdominal aorta sustained during elective laparoscopic gastric band surgery in 2006. The aorta was cut by a Visiport trocar blade at the start of th…

general surgeryanaesthesiaproceduralcommunication
QLDhospital2014-03-31

Platt, Christopher Robert Edmund - Non-inquest findings

69y · Male·Perforated bowel/septicaemia as a result of diverticulitis

A 69-year-old man presented to the ED with abdominal distension, incontinence and dehydration but was discharged with a diagnosis of depression and constipation. He returned 2 days later critically unwell and died of per…

emergency medicinegeneral surgerydiagnosticcommunicationsodium citrate enema

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