217 results
71y · Male·metastatic papillary renal cell carcinoma
Robert Bell-Williams, aged 71, died from metastatic papillary renal cell carcinoma while in lawful custody at Long Bay Hospital on 1 February 2024. Imprisoned since 2012, he was diagnosed with renal cell carcinoma in 202…
71y · Male·Multiple injuries sustained in motorcycle crash
Damian Brian Thompson, aged 71, crashed his motorcycle on a rural road in Tasmania during torrential rain, sustaining severe injuries to his left leg and left hand. He was transported to Launceston General Hospital where…
86y · Male·Left haemothorax complicating rib fractures (not operated), sustained in a fall
James Reilly, 86, fell at home on 8 September 2024 sustaining rib fractures that caused a fatal left haemothorax. Paramedics attended but he declined transfer. When facial droop developed, he was admitted with presumed t…
78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …
A 78-year-old woman died from hypoxic ischaemic encephalopathy following an acute post-surgical arterial bleed that obstructed her airway after hemithyroidectomy. The bleeding complication occurred when she coughed after…
59y · Female·Complications of a pseudo-obstruction on a background of previous anterior resec…
Julie Anne White, 59, died from complications of pseudo-obstruction following previous sigmoid volvulus resection. She had intellectual disability, dementia, schizophrenia, depression, and chronic bowel dysmotility. Admi…
62y · Male·Intraoperative haemorrhage due to metastatic clear cell renal cell carcinoma (su…
A 62-year-old man died from intraoperative haemorrhage during surgery for a renal tumour initially diagnosed as benign anastomosing haemangioma on biopsy but found at autopsy to be metastatic clear cell renal cell carcin…
72y · Male·Complications of a gastroduodenal perforation (palliated) in the setting of mult…
William Anthony Daniel, a 72-year-old SDA resident with intellectual impairment and multiple comorbidities, presented to Box Hill Hospital on 7 November 2024 with postural hypotension, nausea, vomiting and abdominal pain…
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…
85y · Male·Liver ischaemia and portal vein thrombosis complicating emergency cholecystectom…
Kenneth James Anderson, an 85-year-old man with intellectual disability and multiple comorbidities including diabetes, pancreatitis, and gallstones, died following emergency cholecystectomy for acute cholecystitis with M…
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…
2y · Male·Cardiorespiratory arrest in a young child with opioid (morphine) toxicity
David Flynn was a healthy 2-year-8-month-old boy who died after circumcision under sedation with morphine at a private general practice clinic on 7 December 2021. Critical failures included: no fasting instructions despi…
88y · Female·Complications of cholecystectomy surgery
Margaret Mariani, 88, died from complications of laparoscopic cholecystectomy for gallstone-induced pancreatitis. An iatrogenic small bowel perforation, likely caused by inadvertent suturing during closure, led to perito…
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…
79y · Female·Dilated cardiomyopathy with decompensated heart failure not appropriately treate…
A 79-year-old woman with severe COPD and heart failure presented with two weeks of nausea and vomiting. She was diagnosed with left ventricular failure (EF 33%) on day 1 of admission. Two cardiologists had key roles: Dr …
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…
76y · Female·multi-organ failure and sepsis due to complications of cholecystectomy
A 76-year-old woman died from multi-organ failure and sepsis following a laparoscopic cholecystectomy at a rural hospital. During surgery, the surgeon became misoriented in the inflamed surgical field and divided the com…
53y · Male·disseminated malignant melanoma
A 53-year-old man died of disseminated malignant melanoma while incarcerated at Yatala Labour Prison. Initial excision of a large arm mole in November 2019 revealed Stage III melanoma. A January 2020 multi-disciplinary t…
42y · Male·Multiple organ failure due to iatrogenic phenol overdose due to metastatic pancr…
A 42-year-old man with metastatic pancreatic cancer died from multiple organ failure caused by iatrogenic phenol overdose during a celiac plexus block for pain management. The radiologist administered 40ml of 80% phenol …
74y · Male·acute on chronic liver failure complicating common bile duct cholangiocarcinoma …
Stephen John Foster, aged 74, died in hospital from acute on chronic liver failure complicating common bile duct cholangiocarcinoma. He was serving a prison sentence at the time. Initial presentation with jaundice, eleva…
40y · Male·Aspiration pneumonia
Alexander Cameron, a 40-year-old man with complex neurodevelopmental, neurological and psychiatric disorders including epilepsy, autism, and previous neuroleptic malignant syndrome (NMS), died from aspiration pneumonia f…
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