102 results
67y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …
David Fensom, 67, underwent elective fundoplication for hiatus hernia and reflux on 21 September 2010. He developed severe right-sided abdominal pain post-operatively. A laparoscopy on 8 October misinterpreted findings a…
77y · Male·sepsis due to retroperitoneal collection after biliary stent insertion on a back…
A 77-year-old Aboriginal man died from sepsis following a percutaneous transhepatic cholangiography (PTC) procedure that perforated his duodenum. Critical failures included: delayed diagnosis and treatment of peritonitis…
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…
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…
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…
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…
57y · Female·Haemothorax following acute thoracic aortic dissection in a woman with congenita…
Sally Hopwood, 57, with Turner syndrome, coarctation of the aorta, and bicuspid aortic valve, presented to ED on 23 March 2012 with severe acute back and chest pain (8/10). A chest X-ray revealed widened mediastinum. She…
31y · Male·Pulmonary thromboembolism
A 31-year-old man with obesity (BMI 40.2) and sleep apnoea underwent extensive cosmetic surgery in Malaysia (liposuction, abdominoplasty, chest lipectomy, and subsequent facial procedures) across two operations within fi…
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…
76y · Male·multiple organ failure due to large volume aspiration of gastric contents during…
Maurice Nancarrow, 76, died from multiple organ failure following aspiration of gastric contents during anaesthetic induction for cystoscopy on 15 August 2015. He had undergone colorectal surgery on 30 July with complica…
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…
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…
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…
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…
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…
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…
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…
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 …
25y · Female·ruptured splenic artery aneurysm
This ruling concerns a legal dispute over production of documents rather than the clinical circumstances of death itself. Mellanie Joanne Paltridge, 25 years old and 23 weeks pregnant, died from a ruptured splenic artery…
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…
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