112 results
48y · Female·malnutrition in association with sepsis on a background of end stage multiple sc…
A 48-year-old woman with end-stage multiple sclerosis died from malnutrition and sepsis after her husband, her primary carer, failed to provide adequate nutrition via a PEG tube despite receiving training and instruction…
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…
76y · Male·Multiple organ failure due to sepsis with peritonitis and pancreatitis, secondar…
A 76-year-old man died from multiple organ failure following an ERCP procedure for gallstone removal. The procedure itself was appropriate and uneventful. Post-operatively, he developed severe abdominal pain and a CT sca…
49y · Female·Widespread small and large bowel, splenic and hepatic infarction secondary to se…
Susan Bourke, a 49-year-old woman, died from widespread small and large bowel infarction secondary to severe aortic atherosclerosis causing critical stenosis of the superior mesenteric and coeliac arteries. She presented…
86y · Male·Septic shock secondary to urosepsis
Robert Avery, 86, was admitted to Valley Private Hospital for colonoscopy to investigate constipation. After the procedure was cancelled due to respiratory concerns, he was managed with fluid restriction, bowel preparati…
29y · Male·Multiple drug toxicity
Shane John Robinson, a 29-year-old prisoner with complex medical conditions including Crohn's disease, pulmonary embolism, anaemia and schizoaffective disorder, died from multiple drug toxicity in prison. He had been pre…
55y · Male·gastrointestinal haemorrhage due to oesophageal varices due to hepatocellular ca…
Robert McIntosh, a 55-year-old prisoner with undiagnosed cirrhosis of the liver, hepatitis C, and hepatocellular carcinoma, died from gastrointestinal haemorrhage and oesophageal varices. While the coroner found that med…
45y · Female·Pethidine toxicity
Maree Arthur died from pethidine toxicity at home on 2 February 2008, aged 45. She had complex chronic pain from previous surgeries and motor vehicle injury. Her GP, Dr Phillips, prescribed large quantities of pethidine …
65y · Female·Liver failure secondary to paracetamol toxicity
A 65-year-old retired nurse died from paracetamol toxicity and liver failure after taking excessive paracetamol tablets for pain relief following a fractured arm. She presented to hospital on Saturday with a fracture. Cr…
55y · Female·Multiple drug toxicity in a woman with coronary artery atherosclerosis
A 55-year-old woman with complex medical history including chronic pain, previous multiple abdominal surgeries, gastrointestinal disorders, mental health issues including DID, and suicidal ideation died from multiple dru…
9y · Male·sigmoid volvulus
Lawrence Betts, a 9-year-old Aboriginal boy with Goldenhar syndrome and developmental disability including pica (ingesting foreign substances), died from sigmoid volvulus complicated by ingestion of soil, sand, and stone…
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…
7y · Male·Joshua died due to a combination of physical entrapment of his head which occlud…
Joshua, a 7-year-old boy with spastic quadriplegia, epilepsy, and neurological impairment, died following entrapment of his head between hospital bed rails covered with bed bumpers while in hospital for gastroenteritis. …
31y · Male·Acute colonic pseudo-obstruction; death certificate amended to 'unascertained' -…
Cameron Yeates, a 31-year-old man with intellectual disability (IQ 64) and longstanding gastrointestinal issues, died from acute colonic pseudo-obstruction with underlying malnourishment. Key clinical lessons: (1) severe…
38y · Female·Pulmonary Thromboembolism
Kellie Anne Keogh, 38, died from pulmonary thromboembolism on 10 November 2008 after complex pancreatic surgery. She had nephrotic syndrome with decreased anti-thrombin III levels, initially presenting with suspected DVT…
18y · Male·Hypoglycaemic hypoxic-ischaemic encephalopathy, due to massive liver necrosis, d…
An 18-year-old remand prisoner died from acute liver failure secondary to Hepatitis B and C infection. He presented with fever and malaise on 15 February but was assessed only for boils and not thoroughly evaluated. Clin…
78y · Male·Complications of bowel surgery; specifically post-operative chest infection and …
Barry Howroyd, a 78-year-old man, underwent routine colonoscopy on 7 August 2008 which complicated a known bowel carcinoma diagnosis. The procedure caused bowel perforation, diagnosed the next day via CT imaging. Surgica…
50y · Male·Chronic liver disease (alcohol, hepatitis C) with hepatocellular carcinoma and c…
Noel Robert Rogerson, a 50-year-old prisoner with chronic liver disease (alcohol-related cirrhosis and hepatitis C), died from decompensated liver disease with hepatocellular carcinoma on 28 March 2009 at St Vincent's Ho…
62y · Female·gastric necrosis and perforation due to strangulated diaphragmatic hernia
Joyce Wilman, 62, died from gastric necrosis and perforation due to strangulated para-oesophageal hernia whilst detained under Mental Health Act at Queen Elizabeth Hospital. She presented with vomiting and abdominal pain…
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