102 results
65y · Male·peritonitis and necrosis of the bowel following a ruptured appendix
A 65-year-old prisoner with severe triple-vessel coronary artery disease died from peritonitis and bowel necrosis following an appendectomy. Initial surgery for perforated appendicitis was technically difficult but compe…
36y · Male·Intra-abdominal haemorrhage due to rupture of liver and portal vein; also sustai…
Cameron Doomadgee (Mulrunji), a 36-year-old Aboriginal man from Palm Island, died in police custody on 19 November 2004 from intra-abdominal haemorrhage due to rupture of his liver and portal vein. This inquest, re-opene…
39y · Female·heart failure connected to a massive pulmonary embolus as a result of deep vein …
A 39-year-old woman died from acute heart failure due to massive pulmonary embolus from deep vein thrombosis two days after laparoscopic appendicectomy. She presented to ED with abdominal pain and nausea, was diagnosed w…
82y · Female·acute peritonitis, ruptured bowel and incarcerated bowel herniation
An 82-year-old woman admitted with bowel obstruction recovered well initially but suffered a preventable fall in the radiology department when left unattended with heavy IV pumps on her wheelchair, fracturing her hip. Af…
62y · Male·Acute Gastrointestinal Haemorrhage in association with Acute on Chronic Peptic U…
Kenneth Charles Fox, 62, presented to Fremantle Hospital ED on 12 April 2006 with a gastrointestinal bleed after fainting. He was diagnosed with a massive bleed causing hypovolaemic shock and stabilized with fluid resusc…
28y · Male·hypovolemia secondary to haemorrhage from operative exploration of multiple stab…
A 28-year-old Aboriginal male died from hypovolemic shock following operative exploration of multiple stab wounds to the thigh. The death was preventable. Critical failures included: delayed surgery from Friday to Saturd…
30y · Female·Multi-organ failure due to multiple transfusions required for post-operative ble…
Ms Cvitic, a 30-year-old woman with cervical cancer, underwent radical hysterectomy on 11 February 2002. She collapsed on 14 February with signs of hypovolaemic shock (haemoglobin 5.3 g/dL). Dr W. performed emergency lap…
21y · Male·multi-organ failure due to septicaemia of mixed respiratory (bronchopneumonia) a…
Shannon Tang, a 21-year-old from Singapore with severe obesity (BMI 52) and multiple comorbidities including sleep apnoea, underwent elective laparoscopic gastric bypass surgery performed by Dr F.. He died on day 7 post-…
83y · Female·cardiac arrest from severe triple vessel coronary artery disease complicated by …
Margaret Isabel Horsington, aged 83, died from cardiac arrest secondary to severe coronary artery disease, complicated by large bowel obstruction from rectal carcinoma. She presented to Roma Hospital with constipation an…
36y · Male·intra-abdominal haemorrhage due to rupture of liver and portal vein
Mulrunji (Cameron Francis Doomadgee), a 36-year-old Aboriginal man, died from intra-abdominal haemorrhage due to liver rupture following an encounter with Senior Sergeant Christopher Hurley at Palm Island Police Station …
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…
20y · Female·cardiac dysrhythmia/arrest in a 20 year old Down's Syndrome female following abd…
A 20-year-old woman with Down syndrome and Eisenmenger syndrome (cyanotic heart disease with ventricular septal defect) was admitted with abdominal obstruction. After appropriate diagnostic workup, laparotomy was perform…
72y · Female·Peritonitis due to perforated diverticulum in transverse colon
Maria Donatelli, a 72-year-old woman with cardiac and renal disease, presented to Peel Health Campus with abdominal pain and vomiting. She was initially managed conservatively with a provisional diagnosis of pancreatitis…
63y · Male·pneumonia complicating anoxic brain injury, due to post-operative haemorrhage as…
A 63-year-old man died from pneumonia complicating anoxic brain injury following a post-operative haemorrhage from the inferior epigastric artery during ileostomy closure surgery. The critical failure was a 2.5-hour dela…
57y · Male·Multiple organ failure in consequence of peritonitis resulting from complication…
Robert Douglas Dalgleish died from multiple organ failure due to peritonitis resulting from complications of gastric banding surgery. He presented to the ED on 18 July 2002 with abdominal pain and vomiting. Dr Bodnar app…
41y · Female·secondary haemorrhage following gastric banding surgery
A 41-year-old enrolled nurse died from secondary haemorrhage eight days after laparoscopic gastric banding surgery in Darwin. She attended ED on 18 February with post-operative pain; Dr McNair discharged her after two ho…
39y · Male·Hypoxic brain injury due to respiratory obstruction following surgery for dental…
Richard Christopher Jankowski, a 39-year-old man, died from hypoxic brain injury due to respiratory obstruction following emergency surgery for a dental abscess with cellulitis. After initial treatment with antibiotics, …
56y · Female·Multiple injuries including small and large bowel damage, mesenteric damage with…
Sandra Honey, aged 56, died on 16 November 2001 from multiple injuries sustained in a motor vehicle accident on 13 November 2001. She was a passenger in a vehicle driven by her daughter on the Coalfields Highway near Wor…
66y · Female·acute necrotising haemorrhagic mediastinitis
Mrs Pratt, aged 66, underwent elective gastroscopy at Kapunda Hospital. During the procedure she heaved, and blood was noted at the gastro-oesophageal junction. She was discharged the same afternoon with pain, only to re…
28y · Male·Peritonitis and septic shock complicating perforation of the terminal small bowe…
A 28-year-old man with cerebral palsy, microcephaly, and epilepsy presented to the ED with abdominal pain, fever, and signs of deterioration. Triaged as Priority 3 despite these concerning features, he was not seen by a …
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