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VIChospital2022-05-06

Finding into death of Trevor Anthony Peterson

57y · Male·Sepsis from ischemic bowel due to superior mesenteric artery thrombus

Trevor Peterson, a 57-year-old with chronic gut ischemia, underwent mesenteric artery stenting in February 2020. Discharge instructions emphasising dual antiplatelet therapy (DAPT) were not clearly communicated to the va…

vascular surgeryradiologycommunicationsystemaspirin
VIChospital2022-05-05

Finding into death of PX O

49y · Male·Complications of a right superficial femoral artery injury (operated) following …

A 49-year-old man died from complications of a right superficial femoral artery injury sustained when he was struck by a circular saw at a landscaping worksite. Despite receiving immediate first aid, emergency transport …

trauma surgeryvascular surgerysystemcommunication
NSWhospital2022-03-25

Inquest into the death of Anthony Barrett

54y · Male·Bowel ischaemia resulting from acute thrombosis of superior mesenteric artery an…

Anthony Barrett died from bowel ischaemia caused by acute thrombosis of his superior mesenteric artery and coeliac artery stents post-operatively. He had undergone left total knee replacement surgery at Fairfield Hospita…

orthopaedic surgeryvascular surgerycommunicationdiagnosticclopidogrel
VICcommunity2022-01-20

Finding into death of YLM

78y · Male·Ruptured abdominal aortic aneurysm

A 78-year-old man died from rupture of a previously undiagnosed 7.1cm abdominal aortic aneurysm. A CT scan ordered for suspected renal colic incidentally discovered the aneurysm and recommended vascular review. The GP ap…

general practiceradiologycommunicationsystem
NSWhome2021-03-31

Inquest into the death of John Glen LAURENSON

47y · Male·sequelae of ruptured brain aneurysm

John Laurenson, a 47-year-old remand prisoner, died from rupture of a brain aneurysm on 20 June 2017, four days after collapsing in his prison cell. He had multiple intracranial aneurysms identified in 2015-2016, includi…

neurosurgerygeneral practicediagnosticcommunication
NSWhospital2020-02-28

Inquest into the death of Peter ROBIN

56y · Male·Pulmonary embolism with deep vein thrombosis an antecedent cause; coronary arter…

Peter Robin, a 56-year-old man with a medical history of hypercholesterolaemia, hypertension, obesity, and depression, underwent elective dental surgery on 28 October 2015 to remove four wisdom teeth and resect a cyst. H…

oral and maxillofacial surgeryanaesthesiacommunicationsystemoxycodone
NSWcommunity2020-01-24

Into the death of Thomas Redman

18y · Male·Incised wound to right axilla with complete transection of basilic vein, brachia…

Thomas Redman, aged 18, sustained a catastrophic laceration to his right axilla involving complete transection of major arteries and veins after putting his arm through a glass window at a rural property near Gloucester,…

emergency medicinetrauma surgerycommunicationsystemoxygen
TAShospital2019-09-30

Coroner's Finding: Frith, Aaron Douglas

36y · Male·pulmonary embolism due to right deep vein thrombosis following repair of rupture…

Aaron Frith, a 36-year-old man with obesity and hypertension, sustained a ruptured right Achilles tendon on 28 August 2018. He underwent surgical repair on 15 September 2018 and was discharged on aspirin prophylaxis. He …

orthopaedic surgeryemergency medicinediagnosticsystemaspirin
VIChospital2019-08-30

Finding into death of Agostino Cutugno

57y · Male·Small bowel perforation complicating small bowel obstruction arising from intra-…

Agostino Cutugno, a 57-year-old prisoner with intellectual disability (IQ 55) and history of self-inflicted abdominal stab wounds, died from small bowel perforation complicating obstruction due to intra-abdominal adhesio…

general surgeryintensive carecommunicationsystemproton pump inhibitors
VICaged care2019-07-31

Finding into death of Hong Tay

63y · Male·Sepsis in a man with complicated peripheral vascular disease

Hong Tay, a 63-year-old man with extensive peripheral vascular disease, diabetes, and prior amputations, died from sepsis in an aged care facility following a cervical spine fracture sustained in a fall. After conservati…

geriatric medicinepalliative carecommunicationsystemfentanyl
NSWhospital2019-03-22

Inquest into the death of Patrick THOMAS

52y · Male·Intestinal failure/sepsis arising from venous ischemia as a result of superior m…

Patrick Thomas, a 52-year-old man, died from intestinal failure and sepsis following an accidental division of the superior mesenteric vein (SMV) during laparoscopic surgery for colon cancer at Kareena Private Hospital o…

colorectal surgeryintensive carecommunicationsystem
TAScommunity2019-03-08

Coroner's Finding: Paraskevas, Odissefs

56y · Male·pulmonary thromboembolism due to left deep vein thrombosis

A 56-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis. He presented to his GP on 20 January 2017 with persistent dyspnoea and chest pain following a 22-hour flight to Greece and respirat…

general practicecardiologydiagnosticdelay
VIChospital2018-12-03

Finding into death of Anna Agnieszka Bowditch

34y · Female·Complications of fall with fractured ankle and subsequent deep venous thrombosis…

Anna Bowditch, aged 34, died from complications of deep venous thrombosis (DVT) with pulmonary embolism and paradoxical stroke following elective fracture repair surgery. She had multiple known DVT risk factors: immobili…

orthopaedic surgeryanaesthesiaproceduraldiagnosticclonazepam
VIChospital2018-11-19

Finding into death of Robert Humphreys

71y · Male·Aspiration in setting of paralytic ileus in patient in convalescent phase of abd…

A 71-year-old man died from aspiration complicating prolonged paralytic ileus on postoperative day 9 following open abdominal aortic aneurysm repair. Despite clinical signs of persistent ileus (vomiting, abdominal disten…

vascular surgeryintensive carediagnosticdelayatropine
NSWhospital2018-10-22

Inquest into the death of Sandra Cree

71y · Female·Ruptured abdominal aortic aneurysm, with coronary artery atherosclerosis contrib…

Sandra Cree, a 71-year-old woman, died from a ruptured abdominal aortic aneurysm (AAA) after undergoing an elective endovascular repair procedure in Brisbane. She presented to a remote hospital (Lightning Ridge Multi-Pur…

emergency medicinevascular surgerydiagnosticcommunicationgentamicin
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
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
TAShospital2017-05-19

Coroner's Finding: Smith, James Maurice

38y · Male·haemopericardium (pericardial tamponade) due to aortic dissection

James Maurice Smith, 38-year-old male, died from haemopericardium due to aortic dissection. He presented to ED on 9 June 2015 with severe back and abdominal pain, elevated lactate, and neurological symptoms suggesting va…

emergency medicinegeneral surgerydiagnosticcommunicationondansetron
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
QLDhospital2016-11-04

Neitsch, Horst - non-inquest findings

77y · Male·Stroke; cardiogenic shock; severe aortic stenosis with three vessel coronary art…

Mr Neitsch, a 77-year-old with severe aortic stenosis, peripheral vascular disease, and reduced left ventricular function, underwent elective coronary angiography at Princess Alexandra Hospital on 21 May 2015. The proced…

cardiologyvascular surgeryproceduralcommunicationfurosemide

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