21 results
64y · Male·Complications of advanced rectal carcinoma
David Ronald Thompson, a 64-year-old man with severe intellectual disability and complex medical needs, died from complications of advanced rectal carcinoma. He resided in specialist disability accommodation and had been…
82y · Male·Complications of large bowel obstruction in a man with diverticular disease and …
An 82-year-old man died from complications of large bowel obstruction secondary to a sigmoid mass while incarcerated at Port Phillip Prison. He presented with abdominal pain and vomiting following a fall, and imaging con…
82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…
Winifred Carpenter, 82, died 11 days after a right hemicolectomy for colon cancer from peritonitis due to anastomotic leak. Critical failures occurred on discharge day (10 March 2023): clinicians did not recognize her de…
65y · Male·Complications following a malignant bowel obstruction in a man with multiple com…
Murray Noel Haggar, a 65-year-old man with cerebral palsy and intellectual disability living in specialist disability accommodation, died from complications of malignant bowel obstruction. He presented with chronic const…
90y · Female·abdominal sepsis complicating perforated diverticular abscess of the sigmoid col…
Thelma Annie Ogilvy, a 90-year-old woman from rural Victoria, died from abdominal sepsis complicating a perforated diverticular abscess. She presented with bowel obstruction requiring laparotomy on 21 October 2019, was d…
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…
58y · Male·complications of large bowel pseudo-obstruction
Paul Desmond Smith, aged 58, died from complications of large bowel pseudo-obstruction following discharge from hospital after inadequate assessment. He had presented to the ED with lower abdominal pain and severe faecal…
75y · Male·Multiorgan dysfunction syndrome complicating anastomotic leak following hemicole…
A 75-year-old man died from multiorgan dysfunction following an anastomotic leak after hemicolectomy for caecal adenocarcinoma. Initial post-operative recovery appeared normal, but he deteriorated from day 3 onwards. The…
58y · Male·Aspiration pneumonia complicating small bowel obstruction in the setting of rece…
A 58-year-old man died from aspiration pneumonia complicating small bowel obstruction six days after elective laparoscopic subtotal colectomy for colorectal cancer. On post-operative day 6, he developed fever, tachycardi…
52y · Female·Neutropenic sepsis leading to multi-organ failure due to capecitabine toxicity
Mrs L, a 52-year-old woman with T2N0M0 rectal cancer, died from neutropenic sepsis and multi-organ failure secondary to severe capecitabine toxicity on 31 October 2018. She commenced neoadjuvant chemotherapy with capecit…
68y · Male·Pulmonary thromboembolus secondary to deep vein thrombosis
Ronald Wood, a 68-year-old with complex medical history including prior pulmonary emboli, was treated for rectal cancer requiring chemotherapy and major surgery. Warfarin anticoagulation was appropriately ceased due to b…
46y · Male·Complications of stage 4 colorectal cancer in a man with multiple medical comorb…
Timothy Norton, a 46-year-old man with severe intellectual disability, cerebral palsy, epilepsy and chronic constipation, died from complications of stage 4 colorectal cancer. Cancer was discovered on colonoscopy in June…
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.…
36y · Male·Hanging
A 36-year-old male prisoner with complex psychiatric history, substance use disorder, and recent cancer diagnosis died by hanging in prison. Recent mental health assessments (within 3 days) had classified him as low suic…
65y · Female·Aspiration pneumonia following emergency laparotomy for incarcerated umbilical h…
A 65-year-old woman with intellectual disability, congenital blindness, diabetes, and epilepsy presented with an incarcerated umbilical hernia requiring emergency surgery. Post-operative aspiration occurred in recovery w…
58y · Male·ischaemic bowel; chronic megacolon in the setting of constipation, hypothyroidis…
A 58-year-old man with Rubinstein Taybi Syndrome, chronic constipation, hypothyroidism and intellectual disability died from ischaemic bowel secondary to chronic megacolon. He presented to hospital with abdominal distens…
80y · Female·peritonitis due to sigmoid resection margin leak following extended right hemico…
June Olive Pegg, 80, died from peritonitis following anastomotic leak after extended right hemicolectomy for colonic cancer. Critical delays in diagnosis occurred: a PET scan in May 2010 showed a colonic mass, but respir…
35y · Female·Global cerebral ischaemic injury in the setting of post caecal resection for col…
Kerry Anne Golley, a 35-year-old woman with intellectual disability, autism, and epilepsy, presented with recurrent vomiting between December 2011 and February 2012, requiring multiple ED visits and hospital admissions. …
72y · Male·pneumonia in a man with metastatic colon cancer
Lawrence Noyes was a 72-year-old man serving a prison sentence who presented with metastatic colon cancer. He underwent surgery including palliative bypasses and later a gastrostomy and jejunostomy for nutritional suppor…
75y · Female·hypovolaemic shock from excessive blood loss
Lorraine McDonald, age 75, died from hypovolaemic shock due to massive intraoperative bleeding during an anterior resection for rectosigmoid adenocarcinoma. Critical deficiencies included: no pre-admission clinic assessm…
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