Coronial

26 results for small bowel perforation

VIChospital2011-09-22

Finding into death of Leanne Fiona MacKenzie

48y · Female·abdominal sepsis in a woman with coronary artery disease, post-repair small bowe…

…ed peritonitis and was transferred to Northern Hospital on 4 April. She died of abdominal sepsis caused by small bowel perforation following hernia repair, complicated by underlying coronary artery disease. The coroner …

general surgeryintensive care
SAhospital2000-07-21

Coroner's Finding: HOWIESON Julie Ann

43y · Female·sepsis secondary to extensive acute peritonitis following perforation of small b…

43-year-old woman died from sepsis and necrotising fasciitis following small bowel perforation during laparoscopic tubal ligation. She was at high risk due to previous abdominal surge…

gynaecologyanaesthesiadiagnosticdelay
NSWhospital2020-06-12

Inquest into the death of Dat Nhieu HA

45y · Male·abdominal sepsis on a background of metastatic lung carcinoma

A 45-year-old man with advanced metastatic lung cancer died from abdominal sepsis secondary to bowel perforation while imprisoned. He presented with respiratory symptoms in January 2019, was diagnosed with t…

respiratory medicineoncology
VICaged care2024-01-11

Finding into death of Phyllis Joan Porter

72y · Female·Large rectal prolapse and ischaemic bowel

…an with intellectual disability residing in aged care presented with a large rectal prolapse and ischaemic bowel. She was found on the floor of her room with a prolapse containing approximately 80cm of non-viable small

emergency medicinesurgeryfluoxetine
VIChospital2019-08-30

Finding into death of Agostino Cutugno

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

…isoner with intellectual disability (IQ 55) and history of self-inflicted abdominal stab wounds, died from small bowel perforation complicating obstruction due to intra-abdominal adhesions. Care was fragmented across fi…

general surgeryintensive carecommunicationsystemproton pump inhibitors
TAShospital2016-06-27

Coroner's Finding: Mr P

64y · Male·Small bowel infarction due to a volvulus owing to adhesions in the small intesti…

…tal's Emergency Department in October 2012 with severe central abdominal pain. The ED consultant diagnosed bowel obstruction but failed to consider critical complications such as strangulation, perforation, and peritoni…

emergency medicinegeneral surgerydiagnosticdelay
TAShospital2021-02-03

Coroner's Finding: Boon Alison Kim

51y · Female·peritoneal sepsis with multiple organ failure due to perforation of bowel by for…

…l disability and schizoaffective disorder died from peritoneal sepsis and multiple organ failure caused by bowel perforation from a wooden stick. The stick entered her body via her vaginal canal. She presented with abdo…

general surgerycolorectal surgerydiagnostic
NSWhome2017-12-01

Inquest into the death of AF

3y · Female·peritonitis caused by small bowel perforation due to blunt force trauma

A 3-year-old girl died from peritonitis caused by small bowel perforation. Expert evidence established the perforation resulted from blunt force trauma, not natur…

paediatric surgerypaediatricscommunicationsystemparacetamol
VICcommunity2014-12-08

Finding into death of Gerard Alexander Tibballs

66y · Male·Peritonitis secondary to bowel perforation from small bowel obstruction caused b…

…esented with vomiting and diarrhoea. His GP, Dr D., ordered an abdominal X-ray on 23 June 2010, suspecting bowel obstruction but did not mark it urgent. The radiologist, Dr T., identified a small bowel obstruction and a…

general practiceradiologycommunicationdelaymetoclopramide
SAhospital2005-06-03

Coroner's Finding: SORENSEN Ruth Bengta Maria

69y · Female·faecal peritonitis due to small bowel obstruction and perforation due to periton…

…thout diagnosis. She deteriorated rapidly and died at home the next morning from faecal peritonitis due to small bowel obstruction and perforation from peritoneal adhesions. The coroner found the standard of care was se…

emergency medicinesurgerydiagnosticcommunicationprochlorperazine
SAhospital2011-08-05

Coroner's Finding: LEONARD Emily Ruth and HILLMAN Glenys Anne

Female·Emily Ruth Leonard: multi-organ failure due to overwhelming sepsis from a perfor…

…men died following vaginal prolapse surgery performed by the same surgeon, Dr O., with similar mechanisms: bowel perforation leading to peritonitis and sepsis. Mrs Leonard (77) underwent laparoscopic surgery on 30 Octob…

gynaecologyintensive carediagnosticproceduralheparin
NSWhospital2025-08-14

Inquest into the death of Margaret Mariani

88y · Female·Complications of cholecystectomy surgery

… died from complications of laparoscopic cholecystectomy for gallstone-induced pancreatitis. An iatrogenic small bowel perforation, likely caused by inadvertent suturing during closure, led to peritonitis and aspiration…

surgerygeneral surgerycommunicationdelayfentanyl
NSWhospital2012-06-14

Beverly ann murphy finding & recommendations 0701 08

70y · Female·Hypoxic/Ischaemic Encephalopathy consequent upon Cardiorespiratory Arrest and Co…

…l carcinoma on 2 April 2008 at Royal Hospital for Women. The complex surgery was complicated by iatrogenic small bowel perforations. Post-operatively, wound dehiscence and bowel obstruction developed, requiring return t…

gynaecologyoncologydiagnosticcommunication
QLDhospital2007-08-26

Fitter, Maureen

60y · Female·Cardiac tamponade due to ruptured heart due to total parenteral nutrition due to…

…used by TPN fluid leaking into the pericardium through a PICC line inserted to provide nutrition following bowel surgery. The PICC line was inserted under image intensification with appropriate technique and placement a…

colorectal surgerygastroenterologytotal parenteral nutrition
NSWhospital2019-07-22

Inquest into the death of Nicholas Wells

24y · Male·Peritonitis secondary to a perforation of the small bowel

Nicholas Wells, a 24-year-old man, died from peritonitis secondary to small bowel perforation sustained in a motor vehicle accident. Although he was suspected of having a bowel injur…

emergency medicinesurgerydiagnosticcommunicationmethamphetamine
WAhospital2026-02-23

Inquest into the Death of Child MML

11y · Male·bronchopneumonia and small bowel necrosis with perforation, in a boy with multic…

An 11-year-old Aboriginal boy died from bronchopneumonia and small bowel necrosis with perforation, following severe neurological impairment from an inflicted brain injury s…

neurologypaediatricscommunicationsystem
SAhospital2001-08-24

Coroner's Finding: GADALETA Saverio

28y · Male·Peritonitis and septic shock complicating perforation of the terminal small bowe…

…worsening condition. He suffered cardiac arrest 5.5 hours after arrival with peritonitis from a perforated bowel caused by a swallowed Coca-Cola bottle lid. Although earlier diagnosis might not have changed outcome give…

emergency medicinegeneral surgerycommunicationdelayparacetamol
SAhospital2017-06-22

Coroner's Finding: BAARTSE Leila Marijke

9y · Female·peritonitis due to perforated small bowel due to blunt abdominal trauma

Nine-year-old Leila Baartse-Harkin died from peritonitis due to a perforated small bowel sustained when she fell from a swing. Despite three medical encounters within 36 hours, the perforat…

emergency medicinepaediatricsdiagnosticcommunicationparacetamol
NThospital2018-09-21

Inquest into the death of David Fensom

67y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …

…d abdominal pain post-operatively. A laparoscopy on 8 October misinterpreted findings and missed ischaemic bowel—a critical diagnostic error. The expert review identified a 48-hour delay before appropriate laparotomy on…

general surgeryemergency medicinediagnosticcommunicationfentanyl
WAhospital2005-03-03

Inquest into the Death of Giovanni Bertoncini

72y · Male·acute gangrene of colon with probable perforation along with bowel obstruction a…

…s Day 2002 with acute abdominal pain and vomiting. Over two days, his condition deteriorated but ischaemic bowel disease was not diagnosed until the afternoon of 27 December, by which time it was too late for surgical i…

emergency medicinegeneral medicinediagnosticdelayparacetamol

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