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VICaged care2018-10-31

Finding into death of Winifred Jean Morffew

88y · Female·Complications of a pedestrian accident including subarachnoid haemorrhage, subdu…

An 88-year-old woman with multiple comorbidities (diabetes, ischaemic heart disease, cardiomyopathy) was struck by a reversing vehicle at low speed, sustaining subarachnoid haemorrhage, subdural haemorrhage, and fracture…

emergency medicineneurosurgerysystem
NSWhospital2018-10-04

Inquest into the death of D H

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…

anaesthesiageneral surgerydiagnosticproceduralpropofol
NThospital2018-09-21

Inquest into the death of David Fensom

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…

general surgeryemergency medicinediagnosticcommunicationfentanyl
NThospital2018-09-21

Inquest into the death of Henry George Wilson aka Albert Wilson

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…

general surgeryradiologydiagnosticcommunicationpiperacillin/tazobactam
WAhospital2018-06-14

Inquest into the Death of Anne RZEPCZYNSKI

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…

general surgeryintensive carediagnosticdelayantibiotics
NSWhospital2018-06-06

Inquest into the death of Dr Malay Rana

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…

respiratory medicinegeneral surgerycommunicationdiagnosticfentanyl
TAShospital2018-05-30

Coroner's Finding: Forward, Trudi Maree

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…

emergency medicinegeneral surgerydiagnosticdelay
NSWhospital2018-04-26

Inquest into the death of Margaret Ann Pegum

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…

gastroenterologybariatric surgerydiagnosticcommunication
VIChospital2017-12-21

Finding into death of Sally Elizabeth Hopwood

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…

cardiologyemergency medicinediagnosticcommunicationglyceryl trinitrate
VIChome2017-12-04

Finding into death of Leigh Thomas Aiple

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…

plastic and reconstructive surgerygeneral surgerydiagnosticmedicationenoxaparin
QLDhospital2017-06-22

Mead, Gwendoline

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…

colorectal surgerygeneral surgerydiagnosticdelay5-fluorouracil
TAShospital2017-06-16

Coroner's Finding: Baldock, Andrea Eileen

46y · Female·combined effects of aspiration pneumonia due to gastroparesis following sleeve g…

A 46-year-old woman died from aspiration pneumonia due to gastroparesis following sleeve gastrectomy, complicated by ischaemic heart disease. Post-operative recovery was beset with persistent vomiting, dehydration, and e…

general surgerygastroenterologysystemdelay
WAhospital2017-05-03

Inquest into the Death of Edith Catherine BEE

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…

vascular surgerygeneral surgeryproceduralsystem
NThospital2017-03-30

Inquest into the death of Irene Magriplis

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…

general surgeryanaesthesiadiagnosticprocedural
VIChospital2017-02-23

Finding into death of Carey Livingstone James

73y · Male·multisystem organ failure in the context of trauma and limb fracture

A 73-year-old Indigenous man with multiple comorbidities (diabetes, hypertension, obesity, sleep apnoea, ischaemic heart disease) sustained a right ankle fracture following collision with a motor vehicle while riding a m…

emergency medicinegeneral surgerysystempiperacillin/tazobactam
VIChospital2016-09-15

Finding into death of Bernas Hasibuan

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…

general surgeryintensive carediagnosticcommunication
VIChospital2016-07-14

Finding into death of Ross Albert Butler

67y · Male·Faeculent peritonitis due to perforation of a sigmoid volvulus

Ross Butler, a 67-year-old with dementia and Parkinson's disease, presented with abdominal pain and decreased appetite. A sigmoid volvulus was identified and a rectal tube successfully inserted for decompression. Conserv…

general surgeryemergency medicinecommunicationdocumentationmorphine
VIChospital2016-06-24

Finding into death of Graeme John Jennings

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…

general surgeryemergency medicinediagnosticcommunicationindocid
SAhospital2016-05-25

Coroner's Finding: PALTRIDGE Mellanie Joanne

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…

obstetricsemergency medicinediagnosticdelayparacetamol
WAhospital2016-05-18

Inquest into the Death of Janice May SAULYS

69y · Female·multi-organ failure due to sepsis of unknown origin

A 69-year-old woman with diabetes, cardiac disease, and vulnerable kidneys died from multi-organ failure due to sepsis of unknown origin. She presented to a rural hospital on 28 June 2012 with vomiting, dehydration, and …

emergency medicinegeneral practicesystemdelay

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