20 results
33y · Male·Haemoperitoneum secondary to lacerated spleen as a result of peritoneal ascitic …
A 33-year-old man with severe alcoholic liver disease (Child-Pugh C) and poor prognosis died from haemoperitoneum following splenic laceration during a diagnostic ascitic tap procedure. Two junior doctors (HMOs/Basic Phy…
63y · Female·Complications following sedation for percutaneous endoscopic gastrostomy (PEG) t…
Dianne Linford, a 63-year-old woman with profound disability from cerebral palsy and encephalitis, died from complications of sedation for PEG tube insertion. She had a congenital polymicrogyria, a significant neurologic…
64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man …
Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart fai…
38y · Male·abdominal and chest sepsis complicating iatrogenic left pneumothorax and laparot…
A 38-year-old man with chromosome 1 short arm deletion syndrome, intellectual disability, and scoliosis died from sepsis following iatrogenic pneumothorax and emergency laparotomy for small bowel obstruction. He was admi…
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…
58y · Female·lymphangitic carcinomatosis leading to hypoxaemic respiratory failure and cardia…
June Nutter, a 58-year-old woman presenting with weight loss, anorexia, and unexplained shortness of breath, underwent gastroscopy and colonoscopy at a private hospital to investigate suspected gastric pathology. She had…
57y · Male·sepsis and multiple organ failure secondary to aspiration pneumonia
Timothy Fenton, a 57-year-old intellectually disabled man on antiepileptic medications, developed a small bowel ileus after presenting with vomiting and diarrhoea. Following emergency laparotomy, his nasogastric tube was…
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…
33y · Male·complications of acute peritonitis caused by rupture of a duodenal ulcer
Sony William Tran-Bui, aged 33, died from acute peritonitis caused by a ruptured duodenal ulcer while in custody at Silverwater Correctional Centre in November 2013. The death was not preventable given the sudden, unexpe…
82y · Male·Cardiomegaly, myocardial fibrosis and ischaemic coronary artery disease in the c…
An 82-year-old man with extensive comorbidities underwent colonoscopy with argon plasma coagulation (APC) for bleeding angiodysplasia. Prolonged activation intervals during the final third of the procedure caused full-th…
4y · Female·Haemorrhage due to aorto-oesophageal fistula caused by ingestion of a button bat…
A 4-year-old girl died from aorto-oesophageal fistula and haemorrhage caused by a lithium button battery lodged in her oesophagus for at least 3 days. Critical diagnostic failures occurred: the initial GP failed to consi…
57y · Female·small bowel ischaemia; distal gastrectomy
57-year-old woman underwent distal gastrectomy and vagotomy for gastric outlet obstruction in August 2008. Coroner found she suffered an aberrant surgical reconstruction during the procedure, with abnormal bowel anatomy …
79y · Female·pneumonia in the setting of acute peritonitis due to perforated stomach (operate…
Mrs Thelma Katherine Holt, a 79-year-old woman with multiple comorbidities including obesity, vascular disease, hypertension, and prior Nissen fundoplication, underwent placement of a second intragastric balloon on 11 Se…
64y · Male·aspiration pneumonia following insertion of a jejunostomy tube
Ronald Brockel, a 64-year-old with cerebral palsy, oropharyngeal dysphagia, and recurrent aspiration pneumonia, underwent insertion of a feeding jejunostomy tube (FJT) on 23 December 2004 to bypass his stomach and improv…
32y · Female·ischaemic heart disease complicated by upper gastrointestinal haemorrhage
A 32-year-old woman with schizophrenia presented to the emergency department with chest pain radiating to both arms, profuse sweating, and vomiting black material for several days. She also reported black stools. The fir…
68y · Male·Internal haemorrhage due to coagulopathy and upper gastrointestinal varices, cir…
Robert Donald Rawson, a 68-year-old man with end-stage cirrhosis and multiple comorbidities, died hours after undergoing intercostal catheter insertion for pleural effusion drainage at Rockhampton Hospital. While the pro…
44y · Male·cardiac arrhythmia in a man with liver failure due to cirrhosis and focal corona…
Michael John Herrick, a 44-year-old prisoner with end-stage liver cirrhosis secondary to hepatitis C and alcohol abuse, died from cardiac arrhythmia at Sir Charles Gairdner Hospital. He had been receiving aggressive trea…
34y · Male·extensive blood loss from acute gastric erosions following severe scalding of th…
Neil Summerell, a 34-year-old man with intellectual disability, epilepsy, and vision/hearing impairment, died from acute gastric erosions following severe scalding injuries sustained on 29 November 1999. He was scalded t…
45y · Female·Multi-organ failure due to septicaemia and peritonitis due to faecal leakage fro…
A 45-year-old woman died from multi-organ failure following failure of a loop colostomy created for management of an anastomotic leak after bowel cancer surgery. The initial anastomotic leak (1.5 cm) was contained and re…
80y · Male·bronchopneumonia complicated by morphine toxicity
An 80-year-old man with terminal liver disease died from bronchopneumonia complicated by morphine toxicity following a medication administration error. A Graseby infusion pump was incorrectly set at 99mm/hour instead of …
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