107 results
54y · Male·Bowel ischaemia resulting from acute thrombosis of superior mesenteric artery an…
Anthony Barrett died from bowel ischaemia caused by acute thrombosis of his superior mesenteric artery and coeliac artery stents post-operatively. He had undergone left total knee replacement surgery at Fairfield Hospita…
77y · Female·Haemoperitoneum following cholecystectomy
A 77-year-old woman died from haemoperitoneum (intra-abdominal bleeding) three days after elective laparoscopic cholecystectomy. Bleeding from the left inferior epigastric artery was a recognised surgical complication bu…
63y · Male·metastatic rectal carcinoma
Jeremy Scott, a 63-year-old prisoner, died from metastatic rectal carcinoma on 3 July 2017. From 2015 onwards, he reported rectal and anal symptoms including pain, bleeding, and palpable masses, which were repeatedly att…
67y · Male·acute gastrointestinal haemorrhage complicating peptic ulcer of the duodenum wit…
A 67-year-old man died from acute gastrointestinal haemorrhage from a duodenal ulcer following complex post-operative complications from laparoscopic Hartmann's procedure for diverticulitis. Key clinical lessons: (1) Ear…
Female·multi-organ failure
Mrs M died from multi-organ failure following recurrent intra-abdominal sepsis and surgical complications after endoscopic duodenal perforation in June 2019. During resection of a duodenal adenoma, perforation occurred r…
56y · Male·Internal blood loss, complications arising from laparoscopic cholecystectomy
Barry Brown, a 56-year-old man, died from internal bleeding after laparoscopic cholecystectomy due to critical systemic failures in post-operative care and diagnosis. Following hypotension at 7:30pm, nursing staff failed…
80y · Male·acute myocardial ischaemia due to coronary atherosclerosis
Mr Wade, aged 80, died from acute myocardial infarction following knee surgery. On postoperative day 3, he developed chest symptoms, elevated troponin, and hypoxia. An ECG was performed showing acute anterior myocardial …
94y · Female·Complications of metastatic lobular carcinoma of the breast in a woman with deme…
A 94-year-old woman with advanced dementia and metastatic breast cancer died from complications of her malignancy. She presented repeatedly with vomiting due to duodenal obstruction from metastatic tumour, but this was n…
68y · Male·surgical complications following laparoscopic cholecystectomy for cholecystitis,…
Cyril Churchill, a 68-year-old man with multiple comorbidities, died from surgical complications after laparoscopic cholecystectomy for acute cholecystitis. Postoperatively, he developed profound hypotension. The treatin…
51y · Female·peritoneal sepsis with multiple organ failure due to perforation of bowel by for…
A 51-year-old woman with intellectual disability and schizoaffective disorder died from peritoneal sepsis and multiple organ failure caused by bowel perforation from a wooden stick. The stick entered her body via her vag…
65y · Male·ischaemic and hypertensive heart disease with contributing acute cholecystitis (…
A 65-year-old man with hypertension presented with acute cholecystitis, underwent laparoscopic cholecystectomy, and initially recovered well. On post-operative day 7, he experienced chest pain radiating to his jaw. Two E…
66y · Male·hepatic failure, intrahepatic sepsis and intrahepatic haematoma secondary to com…
William Ernest Pears died from hepatic failure, intrahepatic sepsis and haematoma following a laparoscopic cholecystectomy in 2012. During surgery for gallstone disease, the right hepatic duct was damaged and repaired, b…
61y · Female·multi organ failure due to abdominal sepsis
Lesley Arndell, aged 61, died from multi-organ failure due to abdominal sepsis after undergoing a Whipple's procedure for pancreatic cancer. Key clinical lessons include: (1) patients with previous bariatric surgery requ…
36y · Male·Septicaemia and cerebral artery air embolism, due to complications related to cl…
Jamie Lawrence Mitchell, 36, died from septicaemia and cerebral artery air embolism complicating radiofrequency ablation for atrial fibrillation. He developed an atrioesophageal fistula after cardiac ablation at Royal Ad…
71y · Female·pneumonia following cervical spine fracture sustained in motor vehicle collision
Julie Anne Holmes, aged 71, died of pneumonia following a cervical spine fracture sustained in a motor vehicle accident that was not diagnosed during her hospital admission. Critical clinical lessons include: (1) paramed…
44y · Female·pulmonary thromboembolism in a woman with likely myeloproliferative neoplasm
A 44-year-old previously healthy woman with BMI 30.5 and minimal comorbidities (snoring, back pain, knee pain) underwent elective sleeve gastrectomy for weight loss. Nine days post-op she presented with splenic rupture r…
44y · Male·gunshot wound to abdomen
A 44-year-old male died from a gunshot wound to the abdomen sustained during a police response to a domestic violence incident. He became aggressive, wielded a knife, and lunged at police after Taser and pepper spray fai…
58y · Female·Ischaemic small bowel due to bowel obstruction most likely due to a combination …
Mrs Fulham, aged 58, died from ischaemic small bowel due to obstruction from adhesions and Crohn's disease recurrence. On 22 November, she presented to GP with two weeks of diarrhoea, vomiting, nausea, and abdominal pain…
70y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …
Ali Djawas, a 70-year-old Indonesian-born man with comorbidities (hypertension, diabetes, COPD), underwent elective right hemicolectomy on 13 March 2017 for a suspicious ileo-caecal lesion. Biopsies were benign, CT imagi…
71y · Male·Aspiration in setting of paralytic ileus in patient in convalescent phase of abd…
A 71-year-old man died from aspiration complicating prolonged paralytic ileus on postoperative day 9 following open abdominal aortic aneurysm repair. Despite clinical signs of persistent ileus (vomiting, abdominal disten…
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