11 results
75y · Female·multiple organ failure due to severe anaemia secondary to blood loss post electi…
A 75-year-old woman died from multiple organ failure due to severe anaemia after elective hysterectomy surgery. Critical failures occurred: the surgical and anaesthetic teams held conflicting understandings about whether…
71y · Female·complications of metastatic endometrial carcinoma, treated palliatively
Corazon Contreras Keeley, a 71-year-old woman with postmenopausal bleeding, was investigated for possible endometrial cancer. Dr K. performed a hysteroscopy with dilation and curettage (HDC) on 29 November 2019, observin…
62y · Female·Hypovolaemic and cardiogenic shock (hysterectomy) in the context of cardiomegaly…
A 62-year-old woman with significant comorbidities (cirrhosis, cardiomegaly, thrombocytopenia, chronic kidney disease, COPD) died from hypovolaemic and cardiogenic shock during elective total laparoscopic hysterectomy fo…
43y · Female·pulmonary embolism
A 43-year-old woman died from pulmonary embolism after hysteroscopy for investigation of heavy menstrual bleeding. Following the procedure, she developed left leg swelling on day 3. A Venous Doppler Ultrasound was perfor…
38y · Female·neck compression (hanging)
RR, a 38-year-old woman with complex mental health history including PTSD, substance use disorder, and borderline personality traits, was admitted to Bloomfield Hospital on 12 April 2015 following an overdose with stated…
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…
70y · Female·Hypoxic/Ischaemic Encephalopathy consequent upon Cardiorespiratory Arrest and Co…
Beverly Ann Murphy, 70, underwent hysterectomy for endometrial carcinoma on 2 April 2008 at Royal Hospital for Women. The complex surgery was complicated by iatrogenic small bowel perforations. Post-operatively, wound de…
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 O., with similar mechanisms: bowel perforation leading to peritonitis and sepsis. Mrs Leonard (77) underwent laparoscopic surger…
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…
62y · Female·Haemorrhage caused by abdominoperineal excision of the rectum
A 62-year-old woman died of uncontrollable haemorrhage following an abdominoperineal excision of the rectum (APER) at a remote hospital. The coroner found the operation itself was inappropriate: performed for undiagnosed…
43y · Female·sepsis secondary to extensive acute peritonitis following perforation of small b…
43-year-old woman died from sepsis and necrotising fasciitis following small bowel perforation during laparoscopic tubal ligation. She was at high risk due to previous abdominal surgeries and adhesions. A 4-5mm perforati…
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