111 results
48y · Male·Pulmonary thromboembolism
Guy Christian Mason, 48, died from a saddle pulmonary embolism on 17 September 2023, three days after discharge from patellar tendon repair surgery. He had sustained a significant knee injury with multiple ligament ruptu…
70y · Male·metastatic gastric adenocarcinoma
A 70-year-old man with prior bladder cancer was undergoing routine CT surveillance. Stomach cancer signs were clearly visible on February 2017 and February 2018 CT scans but failed to be detected by consulting radiologis…
87y · Female·Oesophageal perforation following an elective oesophageal dilatation, secondary …
87-year-old Helen Mahlis died from oesophageal perforation following an elective balloon dilation procedure at Epworth Richmond for treatment of achalasia. The coroner identified two contributing factors: use of a 35mm b…
86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall
James Reilly, 86, fell at home on 8 September 2024 sustaining rib fractures that caused a fatal left haemothorax. Paramedics attended but he declined transfer. When facial droop developed, he was admitted with presumed t…
78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …
A 78-year-old woman died from hypoxic ischaemic encephalopathy following an acute post-surgical arterial bleed that obstructed her airway after hemithyroidectomy. The bleeding complication occurred when she coughed after…
62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (su…
A 62-year-old man died from intraoperative haemorrhage during surgery for a renal tumour initially diagnosed as benign anastomosing haemangioma on biopsy but found at autopsy to be metastatic clear cell renal cell carcin…
82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…
Winifred Carpenter, 82, died 11 days after a right hemicolectomy for colon cancer from peritonitis due to anastomotic leak. Critical failures occurred on discharge day (10 March 2023): clinicians did not recognize her de…
79y · Female·Dilated cardiomyopathy with decompensated heart failure not appropriately treate…
A 79-year-old woman with severe COPD and heart failure presented with two weeks of nausea and vomiting. She was diagnosed with left ventricular failure (EF 33%) on day 1 of admission. Two cardiologists had key roles: Dr …
76y · Female·multi-organ failure and sepsis due to complications of cholecystectomy
A 76-year-old woman died from multi-organ failure and sepsis following a laparoscopic cholecystectomy at a rural hospital. During surgery, the surgeon became misoriented in the inflamed surgical field and divided the com…
42y · Male·Multiple organ failure due to iatrogenic phenol overdose due to metastatic pancr…
A 42-year-old man with metastatic pancreatic cancer died from multiple organ failure caused by iatrogenic phenol overdose during a celiac plexus block for pain management. The radiologist administered 40ml of 80% phenol …
74y · Male·small intestinal ischaemia caused by aortic atherosclerosis
A 74-year-old man presented to hospital with abdominal pain following a fall. He developed hypotension, fever, tachycardia, and elevated inflammatory markers consistent with sepsis within hours of admission. Despite clea…
73y · Male·sepsis due to ischemic gut due to occlusion of the superior mesenteric artery
A 73-year-old man presented with acute severe abdominal pain caused by superior mesenteric artery (SMA) occlusion. Initial CT angiogram at 12:30am was reported as normal; the SMA occlusion was not identified until 4:45am…
73y · Female·sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopi…
A 73-year-old woman died from sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopic revision of gastric bypass surgery. She had complex medical history with multiple post-operative complicatio…
70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia
70-year-old Sean Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner identified multiple significant failing…
46y · Male·sepsis following haemorrhoidectomy
46-year-old Justin Mark Dobson died from sepsis following a routine haemorrhoidectomy on 17 July 2019. He was discharged to the ward overnight but deteriorated significantly from 11:00 am on 18 July, showing hypotension,…
74y · Male·Aspiration of gastric contents due to paralytic ileus following Whipple surgery …
William Searle, a 74-year-old prisoner, died from aspiration of gastric contents following a Whipple procedure for recurrent ampullary adenoma. The clinical lessons involve recognition of gastroparesis risk in high-risk …
79y · Male·complications of peritonitis
A 79-year-old man with multiple comorbidities presented with a perforated bowel requiring emergency Hartmann's procedure. The operating surgeon, Dr L.-Ming Schmidt, made a catastrophic surgical error by exteriorising the…
58y · Male·complications of large bowel pseudo-obstruction
Paul Desmond Smith, aged 58, died from complications of large bowel pseudo-obstruction following discharge from hospital after inadequate assessment. He had presented to the ED with lower abdominal pain and severe faecal…
64y · Male·Peritonitis, due to or as a consequence of a ruptured gallbladder, due to or as …
Dennis Childs, a 64-year-old Indigenous man serving a life sentence, died from peritonitis secondary to a ruptured gallbladder. On 8 December 2018, he presented with abdominal pain at the correctional centre but refused …
71y · Male·sepsis caused by mediastinal empyema (abscess) which complicated perforation of …
Terence Carroll, 71, died from sepsis and mediastinal empyema following oesophageal perforation during rigid oesophagoscopy for stricture dilation. Critical failures included: CT scan showing suspicious oesophageal thick…
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