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VIChospital2013-06-05

Finding into death of Lenin McLarty

68y · Male·Dilated cardiomyopathy with previous aortic valve replacement and aortic graft

A 68-year-old man with aortic valve replacement died from undiagnosed dilated cardiomyopathy, with retroperitoneal haemorrhage as a contributing factor. He developed a large perinephric haematoma (1900mL) secondary to ov…

cardiothoracic surgeryemergency medicinecommunicationsystemwarfarin
VIChospital2013-01-22

Finding into death of Daryl Wayne Nankervis

64y · Male·Ischaemic bowel and spleen infarction secondary to occlusion of splenic artery a…

A 64-year-old man died from bowel and spleen infarction caused by surgical clips incorrectly placed on the splenic and superior mesenteric arteries during laparoscopic nephrectomy for renal cell carcinoma. The surgeon mi…

urologysurgerydiagnosticprocedural
QLDhospital2011-06-09

Tranby, James Errol

64y · Male·necrotising fasciitis precipitated by a fishbone perforating his rectum, leading…

James Tranby, a 64-year-old Indigenous diabetic prisoner, presented with a fish bone lodged in his rectum on 3 December 2008. Following removal on 5 December, he developed progressive sepsis leading to necrotising fascii…

general surgerycolorectal surgerydiagnosticdelayinsulin
SAaged care2009-06-26

Coroner's Finding: DAVIES Harold Leslie

87y · Male·multi organ failure due to septic shock complicating urinary tract infection and…

An 87-year-old man with atrial fibrillation on warfarin developed septic shock and multi-organ failure following traumatic bladder catheterisation. Two catheterisation attempts occurred on 15 July 2005: an unsuccessful a…

general practiceurologyproceduralcommunicationwarfarin
WAhospital2004-06-17

Inquest into the Death of Edmiston

41y · Female·Peritonitis following surgical procedure to the urinary bladder, due to infected…

Cheryl Lee Edmiston, a healthy 41-year-old woman, died of peritonitis and sepsis following minor bladder procedures (cystoscopy, hydrodilatation, and biopsy) at Joondalup Health Campus on 14 February 2003. The biopsies w…

urologygeneral surgerydiagnosticmedicationamoxicillin
NThospital2003-07-17

Inquest into the death of Lennie Pinawrut

67y · Male·acute renal failure with associated severe acidosis and hyperkalemia

A 67-year-old Aboriginal male with dementia was discharged from Royal Darwin Hospital on 4 November 2001 following cystoscopy and bladder neck incision for suspected obstruction. Critical communication failures meant the…

urologysurgerycommunicationdelaygentamicine

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