16 results
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…
40y · Male·Acute hepatic and renal failure in the setting of postoperative haemorrhage foll…
A 40-year-old man with obesity, COPD, diabetes and hypertension died from acute hepatic and renal failure following postoperative haemorrhage after left radical nephrectomy for a 10cm renal cell carcinoma. The surgeon ap…
56y · Male·sepsis
A 56-year-old man died from sepsis following elective bladder cancer surgery. Post-operative infection developed with clear clinical signs: elevated CRP (205-284 mg/L), positive bacterial cultures (Staphylococcus aureus,…
53y · Female·multiple organ failure as a result of septic shock
Pauline Kessell, aged 53, died from septic shock caused by overwhelming sepsis following endoscopic pyeloscopy with laser lithotripsy for a 5cm infected staghorn calculus on 12 August 2015. Critical clinical lessons: (1)…
48y · Female·Combined toxic effect of prescription and non-prescription medications including…
Lauren Johnstone, aged 48, died from the combined toxic effects of prescription and non-prescription sedative medications including oxycodone, tramadol, codeine, zopiclone, doxylamine and fluoxetine. She had undergone mu…
78y · Male·metastatic malignancy (unknown primary) with contributing right-sided heart fail…
Leonard Edward Dodson, aged 78, died in custody from metastatic liver cancer (unknown primary) with contributing right-sided heart failure. He had prostate cancer diagnosed in 2010 via elevated PSA (20ng/ml) but was not …
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…
75y · Male·left retroperitoneal haemorrhage associated with lumbar spine surgery
A 75-year-old man with complex comorbidities including Parkinson's disease and cognitive impairment underwent two-stage lumbar spine surgery for degenerative disc disease with stenosis. Post-operatively, he developed a r…
86y · Male·Sepsis with septic shock, due to urinary tract infection, pyelonephritis (kidney…
An 86-year-old man died from sepsis and septic shock secondary to urinary tract infection, pyelonephritis and prostatic infection. He presented to his GP in March 2015 with dizziness and reported urinary incontinence and…
72y · Male·Metastatic bladder cancer; likely mechanism pulmonary embolism from combined eff…
A 72-year-old male underwent hip replacement despite undiagnosed metastatic bladder cancer. Following referral from his GP in May 2014 for an ultrasound showing bladder wall irregularities suspicious for cancer, urologis…
66y · Male·carcinomatosis complicated by recurrent sepsis and multisystem failure in a man …
A 66-year-old man with renal cell carcinoma died in hospital from carcinomatosis with sepsis and multisystem failure. Critical clinical lesson: haematuria in 2005 was not adequately investigated with imaging despite recu…
48y · Male·myocardial infarction due to ischaemic heart disease due to hypertension
A 48-year-old man died from myocardial infarction due to ischaemic heart disease and hypertension shortly after undergoing urology surgery. Critical failures in clinical communication prevented recognition of undiagnosed…
55y · Male·Multi-system failure complicating intra-operative haemorrhage due to inadvertent…
Robert Vivian Hawkins, a 55-year-old man, died from multi-system failure following inadvertent ligation of the superior mesenteric artery (SMA) during laparoscopic nephrectomy for renal cell carcinoma. Dr Jonathan Lewin …
64y · Male·Ischaemic bowel and spleen infarction secondary to occlusion of splenic artery a…
A 64-year-old man died from bowel and spleen infarction caused by surgical clips incorrectly placed on the splenic and superior mesenteric arteries during laparoscopic nephrectomy for renal cell carcinoma. The surgeon mi…
64y · Male·necrotising fasciitis precipitated by a fishbone perforating his rectum, leading…
James Tranby, a 64-year-old Indigenous diabetic prisoner, presented with a fish bone lodged in his rectum on 3 December 2008. Following removal on 5 December, he developed progressive sepsis leading to necrotising fascii…
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…
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