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TAShospital2014-03-14

Coroner's Finding: Little, Neita Jean

79y · Female·aspiration pneumonia caused by aspiration of emesis secondary to small bowel obs…

Mrs Little, 79, died from aspiration pneumonia caused by small bowel obstruction post-hysterectomy surgery. The obstruction resulted from both pre-existing adhesions and a post-operative haematoma at the surgical site. C…

gynaecologyanaesthesiadiagnosticcommunicationrivaroxaban
QLDhospital2014-01-31

George, Lynda Margaret - Non-inquest findings

60y · Female·Peritonitis due to anastomotic leak following subtotal colectomy for treatment o…

60-year-old woman died from septic shock due to anastomotic leak following subtotal colectomy for synchronous bowel cancers. Early postoperative bronchospasm complicated clinical assessment, leading focus on respiratory …

general surgerycolorectal surgerydiagnosticcommunication
WAhospital2013-11-29

Inquest into the Death of Jones, Wilma Ray

75y · Female·Abdominal infection following surgery (repair of recurrent umbilical hernia) - s…

Wilma Ray Jones, 75, died of abdominal infection and sepsis following uncomplicated umbilical hernia repair. Post-mortem revealed ischaemic bowel with infarction, likely caused by superior mesenteric artery occlusion tri…

general surgeryanaesthesiadelaysystemephedrine
VIChome2013-11-27

Finding into death of Andrew Gilmore

17y · Male·intra-abdominal haemorrhage complicating partial pancreatectomy for traumatic pa…

Andrew Gilmore, a 17-year-old fit and well boy, suffered traumatic pancreatic rupture from a football injury on 9 May 2009. Distal pancreatectomy was performed at Alfred Hospital on 11 May. He was discharged to Hospital …

general surgeryemergency medicinecommunicationdelayoxycodone
SAhospital2013-09-30

Coroner's Finding: GIANNINI Pasquale

68y · Male·infarction of the small and large bowel due to superior mesenteric artery thromb…

A 68-year-old man with extensive systemic vascular disease presented with 10 days of nonspecific abdominal pain. Initial presentations at local hospital and GP were attributed to possible gallstones or gastritis based on…

general practiceemergency medicinediagnosticdelayaugmentin duo
VIC2013-08-19

Finding into death of TH

2y · Female·Blunt force injury to the abdomen

A two-year-old girl died from blunt force injury to the abdomen, sustaining internal injuries including pancreatic rupture, jejunal rupture, and liver trauma with significant intra-abdominal hemorrhage. Evidence indicate…

paediatric surgeryemergency medicinedelaysystem
VIChospital2013-08-13

Finding into death of Thelma Katherine Holt

79y · Female·pneumonia in the setting of acute peritonitis due to perforated stomach (operate…

Mrs Thelma Katherine Holt, a 79-year-old woman with multiple comorbidities including obesity, vascular disease, hypertension, and prior Nissen fundoplication, underwent placement of a second intragastric balloon on 11 Se…

gastroenterologygeneral surgerydiagnosticproceduralsertraline
WAhome2013-05-16

Inquest into the Death of Levissianos, Katina

55y · Female·Aspiration of Gastric Contents in Association with Gastric Necrosis in a patient…

A 55-year-old woman died of aspiration following gastric necrosis associated with a gastric band device inserted in 2008. She presented with vomiting and feeling unwell starting 31 October 2009, but never complained of p…

general surgerybariatric surgerycommunicationdiagnosticamoxicillin/clavulanate
WAhospital2013-01-17

Inquest into the Death of Mckay-Hall, Julienne Maria

46y · Female·Complications following cardiorespiratory arrest in association with an air embo…

A 46-year-old woman died from air embolism during a gastroscopy to manage complications from bariatric surgery. The initial laparoscopic sleeve gastrectomy on 9 November 2007 had a staple misfire that was inadequately re…

general surgerybariatric surgerydiagnosticcommunicationmorphine
VIChospital2012-12-14

Finding into death of Jeanette Brown

66y · Female·Multi-organ failure associated with haemorrhage and sepsis following cholecystec…

Mrs Jeanette Brown, 66, died from multi-organ failure following post-operative haemorrhage after elective laparoscopic cholecystectomy. Arterial clips applied to the cystic artery during surgery were inadequately secured…

general surgeryanaesthesiaproceduralcommunicationamlodipine
QLDhospital2012-09-06

Parry, Nerida Ann

63y · Female·bile peritonitis as a complication from a laparoscopic cholecystectomy

A 63-year-old woman died from bile peritonitis following laparoscopic cholecystectomy. The surgeon's intraoperative management was appropriate with no identified injuries. However, critical clinical deterioration on post…

general surgeryanaesthesiadiagnosticcommunication
VIChospital2012-03-02

Finding into death of Elsa Harrington

45y · Female·Multisystem organ failure secondary to acute liver failure associated with parac…

Elsa Harrington, a 45-year-old woman, died from acute liver failure secondary to paracetamol toxicity in November 2002. She was admitted post-hysterectomy with bowel obstruction and underwent adhesion surgery. Following …

general surgerycardiologydiagnosticcommunicationparacetamol
WAhospital2012

Inquest into the Death of Keogh

38y · Female·Pulmonary Thromboembolism

Kellie Anne Keogh, 38, died from pulmonary thromboembolism on 10 November 2008 after complex pancreatic surgery. She had nephrotic syndrome with decreased anti-thrombin III levels, initially presenting with suspected DVT…

general surgeryintensive carecommunicationdelaywarfarin
VIChospital2011-12-16

Finding into death of Lorraine Valerie McDonald

75y · Female·hypovolaemic shock from excessive blood loss

Lorraine McDonald, age 75, died from hypovolaemic shock due to massive intraoperative bleeding during an anterior resection for rectosigmoid adenocarcinoma. Critical deficiencies included: no pre-admission clinic assessm…

general surgerycolorectal surgerydiagnosticprocedural
QLDhospital2011-11-04

Smith, Darryl Robert

34y · Male·Air embolism and severe haemorrhage due to perforation of the right subclavian v…

Darryl Smith, aged 34, died following emergency surgery for a fractured clavicle at Sunnybank Private Hospital. During the final drilling of the sixth screw hole, the surgeon's drill penetrated the underlying right subcl…

orthopaedic surgeryanaesthesiaproceduraldelayadrenaline
SAhospital2011-09-23

Coroner's Finding: BLYTHE Dorothy Josephine

81y · Female·ischaemic bowel

An 81-year-old woman with longstanding depression and multiple comorbidities fell and fractured her humerus in March 2009. During rehabilitation, she became increasingly depressed and self-neglectful, refusing food and c…

psychiatrygeneral surgerydiagnosticdelay
VIChospital2011-08-31

Finding into death of Barry Wilson Howroyd

78y · Male·Complications of bowel surgery; specifically post-operative chest infection and …

Barry Howroyd, a 78-year-old man, underwent routine colonoscopy on 7 August 2008 which complicated a known bowel carcinoma diagnosis. The procedure caused bowel perforation, diagnosed the next day via CT imaging. Surgica…

gastroenterologygeneral surgerycommunicationsystem
SAhospital2011-08-05

Coroner's Finding: LEONARD Emily Ruth and HILLMAN Glenys Anne

Female·Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perfor…

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 sur…

gynaecologyintensive carediagnosticproceduralheparin
QLDhospital2011-06-09

Tranby, James Errol

64y · Male·necrotising fasciitis precipitated by a fishbone perforating his rectum, leading…

James Tranby, a 64-year-old Indigenous diabetic prisoner, presented with a fish bone lodged in his rectum on 3 December 2008. Following removal on 5 December, he developed progressive sepsis leading to necrotising fascii…

general surgerycolorectal surgerydiagnosticdelayinsulin
WAhospital2011-05-12

Inquest into the Death of Walden

68y · Female·Multi-organ failure associated with septic shock following duodenal perforation …

Athenia Hana Walden, 68, died from multi-organ failure and septic shock following duodenal perforation during laparoscopic surgery at Swan District Hospital on 8 May 2008. Surgery was performed to remove her gallbladder,…

general surgerygeneral practicediagnosticcommunicationpethidine

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