52y · Male·pulmonary thromboembolism due to pancreatic contusion and necrosis from motorcyc…
…when his motorcycle struck a rock while negotiating a corner. He was transported to hospital, underwent exploratory laparotomy and returned to theatre for re-look and drain adjustment. Initial recovery appeared good; ho…
73y · Male·sepsis due to ischemic gut due to occlusion of the superior mesenteric artery
…4:45am—over 4 hours later—when surgical staff reviewed the scan. This delay meant the patient underwent exploratory laparotomy at Launceston General Hospital (LGH) rather than proceeding directly to Royal Hobart Hospita…
81y · Female·ischaemic bowel
…h Act detention. On 9 May 2009, her physical health acutely declined with shock-like symptoms. Emergency laparotomy revealed extensive bowel ischaemia deemed incompatible with life. She died the following morning. The co…
74y · Male·Intra-abdominal haemorrhage complicating elective umbilical hernia repair
…ted an unrecognised coagulopathy risk. Earlier recognition and aggressive management might have allowed exploratory laparotomy and bleeding control.
79y · Female·multiple organ failure sustained from injuries received when struck by a truck a…
Mrs Pamela Bernice Gee, aged 79, died from multiple organ failure following severe injuries sustained in a motor vehicle accident. She was struck by a refuse truck driven by Eric Flight as she crossed Cattley Street on a…
88y · Male·Multiple injuries sustained in a motor vehicle collision (pedestrian)
An 88-year-old man died from multiple injuries sustained when struck by a motor vehicle while crossing a poorly-lit road as a pedestrian. He suffered bilateral pelvic fractures, lumbar spine fractures, aortic transection…
58y · Female·Haemorrhagic shock complicating pulmonary thromboembolism in the setting of deep…
A 58-year-old woman with obesity (BMI 38) sustained a metatarsal fracture and was treated with a below-knee plaster cast by her GP. Despite appropriate initial assessment and consultation with a haematologist regarding V…
66y · Female·Multi-organ failure associated with haemorrhage and sepsis following cholecystec…
Mrs Jeanette Brown, 66, died from multi-organ failure following post-operative haemorrhage after elective laparoscopic cholecystectomy. Arterial clips applied to the cystic artery during surgery were inadequately secured…
65y · Male·Severe neutropenic sepsis and multi-organ failure secondary to severe mucositis …
A 65-year-old man with stage 3 rectal cancer died from severe neutropenic sepsis and multi-organ failure secondary to probable dihydropyrimidine dehydrogenase (DPD) deficiency when treated with capecitabine chemotherapy.…
79y · Male·complications of peritonitis
A 79-year-old man with multiple comorbidities presented with a perforated bowel requiring emergency Hartmann's procedure. The operating surgeon, Dr L.-Ming Schmidt, made a catastrophic surgical error by exteriorising the…
71y · Male·Complications following a right hepatic artery injury following an open cholecys…
A 71-year-old man with myelofibrosis and prior abdominal surgery died from complications of a right hepatic artery injury during open cholecystectomy for acute cholecystitis. The operative decision was reasonable and the…
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…
67y · Female·Intra-abdominal sepsis complicating an anastomotic leak following elective surge…
A 67-year-old woman died from intra-abdominal sepsis following an anastomotic leak from elective colorectal surgery to repair a vesico-colic fistula. The initial surgery on 1 November 2017 was appropriately performed, an…
74y · Male·Sepsis secondary to fistulating Crohn's disease and post-surgery complications f…
Christopher Essery, a 74-year-old man with complex fistulating Crohn's disease, died from sepsis following surgery on 24 January 2019. He was transferred to Princess Alexandra Hospital (PAH) on 31 August 2018 for special…
0y · Male·hypoxia due to intrauterine pneumonia and haemorrhage with uterine rupture in a …
A neonate died shortly after birth from hypoxia due to intrauterine pneumonia, haemorrhage and uterine rupture following prolonged rupture of membranes during a planned vaginal birth after caesarean (VBAC). The mother at…
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…
2y · Unknown·Hypoxic-ischaemic encephalopathy following sepsis related to abdominal surgical …
BCT was a 2-year-old Aboriginal child with complex needs from a genetic disorder (CAMTA1 mutation) who died from hypoxic-ischaemic encephalopathy following sepsis related to bowel perforation after a percutaneous endosco…
16y · Male·mid-gut volvulus and bowel obstruction, leading to ischaemic bowel and related c…
Finlay Browne, a 16-year-old with Down syndrome, presented to Bathurst Base Hospital on 30 September 2016 with acute abdominal pain and vomiting. Despite clear clinical signs—including a lactate of 7.2 mmol/L (grossly ab…
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