103 results
59y · Female·sepsis due to faecal peritonitis due to perforation of sigmoid colon complicatin…
A 59-year-old woman died from sepsis due to faecal peritonitis following a bowel perforation during laparoscopic oophorectomy for a benign ovarian cyst. The perforation was repaired during the initial surgery, but the re…
36y · Male·Intra-abdominal haemorrhage due to rupture of liver and portal vein; also sustai…
Cameron Doomadgee (Mulrunji), a 36-year-old Aboriginal man from Palm Island, died in police custody on 19 November 2004 from intra-abdominal haemorrhage due to rupture of his liver and portal vein. This inquest, re-opene…
39y · Female·heart failure connected to a massive pulmonary embolus as a result of deep vein …
A 39-year-old woman died from acute heart failure due to massive pulmonary embolus from deep vein thrombosis two days after laparoscopic appendicectomy. She presented to ED with abdominal pain and nausea, was diagnosed w…
62y · Male·Acute Gastrointestinal Haemorrhage in association with Acute on Chronic Peptic U…
Kenneth Charles Fox, 62, presented to Fremantle Hospital ED on 12 April 2006 with a gastrointestinal bleed after fainting. He was diagnosed with a massive bleed causing hypovolaemic shock and stabilized with fluid resusc…
28y · Male·hypovolemia secondary to haemorrhage from operative exploration of multiple stab…
A 28-year-old Aboriginal male died from hypovolemic shock following operative exploration of multiple stab wounds to the thigh. The death was preventable. Critical failures included: delayed surgery from Friday to Saturd…
30y · Female·Multi-organ failure due to multiple transfusions required for post-operative ble…
Ms Cvitic, a 30-year-old woman with cervical cancer, underwent radical hysterectomy on 11 February 2002. She collapsed on 14 February with signs of hypovolaemic shock (haemoglobin 5.3 g/dL). Dr W. performed emergency lap…
9y · Male·Head injury (epidural haematoma with cerebral coning following craniotomy)
Dwayne Michael Jones, aged 9, had Trisomy 10, a rare congenital chromosomal disorder causing severe developmental delay and neurological abnormalities. On 11 April 2000, he fell from a computer desk and struck his head. …
21y · Male·multi-organ failure due to septicaemia of mixed respiratory (bronchopneumonia) a…
Shannon Tang, a 21-year-old from Singapore with severe obesity (BMI 52) and multiple comorbidities including sleep apnoea, underwent elective laparoscopic gastric bypass surgery performed by Dr F.. He died on day 7 post-…
31y · Female·cerebral anoxia following attempted intubation pre-surgery in a woman with torti…
Rachael Anne Rasmussen, a 31-year-old mother of three with severe neck deformities (torticollis, dysmorphia, short rigid neck), died on 17 June 2003 from cerebral anoxia following attempted intubation at Joondalup Health…
83y · Female·cardiac arrest from severe triple vessel coronary artery disease complicated by …
Margaret Isabel Horsington, aged 83, died from cardiac arrest secondary to severe coronary artery disease, complicated by large bowel obstruction from rectal carcinoma. She presented to Roma Hospital with constipation an…
36y · Male·intra-abdominal haemorrhage due to rupture of liver and portal vein
Mulrunji (Cameron Francis Doomadgee), a 36-year-old Aboriginal man, died from intra-abdominal haemorrhage due to liver rupture following an encounter with Senior Sergeant Christopher Hurley at Palm Island Police Station …
72y · Female·Peritonitis due to perforated diverticulum in transverse colon
Maria Donatelli, a 72-year-old woman with cardiac and renal disease, presented to Peel Health Campus with abdominal pain and vomiting. She was initially managed conservatively with a provisional diagnosis of pancreatitis…
72y · Male·acute gangrene of colon with probable perforation along with bowel obstruction a…
Giovanni Bertoncini, a 72-year-old man with diabetes and cardiac disease, presented to Sir Charles Gairdner Hospital on Christmas Day 2002 with acute abdominal pain and vomiting. Over two days, his condition deteriorated…
63y · Male·pneumonia complicating anoxic brain injury, due to post-operative haemorrhage as…
A 63-year-old man died from pneumonia complicating anoxic brain injury following a post-operative haemorrhage from the inferior epigastric artery during ileostomy closure surgery. The critical failure was a 2.5-hour dela…
41y · Female·Peritonitis following surgical procedure to the urinary bladder, due to infected…
Cheryl Lee Edmiston, a healthy 41-year-old woman, died of peritonitis and sepsis following minor bladder procedures (cystoscopy, hydrodilatation, and biopsy) at Joondalup Health Campus on 14 February 2003. The biopsies w…
57y · Male·Multiple organ failure in consequence of peritonitis resulting from complication…
Robert Douglas Dalgleish died from multiple organ failure due to peritonitis resulting from complications of gastric banding surgery. He presented to the ED on 18 July 2002 with abdominal pain and vomiting. Dr Bodnar app…
39y · Male·Hypoxic brain injury due to respiratory obstruction following surgery for dental…
Richard Christopher Jankowski, a 39-year-old man, died from hypoxic brain injury due to respiratory obstruction following emergency surgery for a dental abscess with cellulitis. After initial treatment with antibiotics, …
66y · Female·acute necrotising haemorrhagic mediastinitis
Mrs Pratt, aged 66, underwent elective gastroscopy at Kapunda Hospital. During the procedure she heaved, and blood was noted at the gastro-oesophageal junction. She was discharged the same afternoon with pain, only to re…
82y · Female·peritonitis due to a perforated viscus (proximal jejunum) resulting from motor v…
An 82-year-old woman suffered a motor vehicle accident causing blunt abdominal trauma. Despite initial clinical assessment appearing adequate, a perforated jejunum with developing peritonitis was not diagnosed until earl…
28y · Male·Peritonitis and septic shock complicating perforation of the terminal small bowe…
A 28-year-old man with cerebral palsy, microcephaly, and epilepsy presented to the ED with abdominal pain, fever, and signs of deterioration. Triaged as Priority 3 despite these concerning features, he was not seen by a …
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