37 results
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 …
68y · Female·haemopericardium resulting from perforation of the pericardial sac during laparo…
Mrs Christine Flynn, aged 68, died from haemopericardium and pericardial tamponade following laparoscopic hiatus hernia repair. A 2mm perforation of the pericardial sac occurred during surgery, likely from mesh tacks pla…
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…
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 Liu-Ming Schmidt, made a catastrophic surgical error by exteriorising th…
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…
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…
76y · Male·Sepsis due to pulmonary valve endocarditis and cardiac abscess due to Staphyloco…
A 76-year-old man died from sepsis caused by Staphylococcus aureus endocarditis and cardiac abscess. An intravenous cannula inserted during day surgery on 29 November 2018 was not removed before discharge, despite hospit…
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…
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…
56y · Male·Hypoxia and cardiac arrest with contributing conditions of Ischaemic Heart Disea…
A 56-year-old man with diabetes, ischaemic heart disease, morbid obesity, and an implanted defibrillator underwent minor toe debridement surgery. The anaesthetist failed to conduct an adequate pre-operative assessment, u…
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…
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…
80y · Female·Gas embolism complicating surgical repair of an atherosclerotic aortic aneurysm …
An 80-year-old woman with multiple comorbidities (COPD, renal impairment, cardiac disease) underwent complex endoluminal repair of a thoracoabdominal aortic aneurysm at a private hospital. The procedure required use of C…
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…
29y · Female·Exsanguination post tubal ligation procedure
A 29-year-old woman died from exsanguination following an iatrogenic injury during elective laparoscopic tubal ligation at a regional hospital. A vascular injury to the right external iliac artery occurred during the pro…
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 …
62y · Female·Multi-organ failure due to lacerated abdominal aorta complicating laparoscopic b…
A 62-year-old woman died from multi-organ failure caused by a lacerated abdominal aorta sustained during elective laparoscopic gastric band surgery in 2006. The aorta was cut by a Visiport trocar blade at the start of th…
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 …
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…
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