19 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…
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…
70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia
70-year-old Sean Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner identified multiple significant failing…
Female·Not definitively stated in judgment; death followed complications from initial s…
This judgment concerns a pre-inquest motion by the Christian Congregation of Jehovah's Witnesses challenging the scope of a coronial inquiry into Heather Winchester's death. Mrs Winchester died following emergency surger…
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…
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…
72y · Male·Complications of subtotal colectomy for diffuse polyposis and invasive adenocarc…
Melvin Lynch, aged 72, died in custody at Prince of Wales Hospital on 9 December 2019, nine days after elective subtotal colectomy for bowel cancer. Post-operatively, he developed complications including pleural effusion…
80y · Male·metastatic hepatocellular carcinoma
Cemil Guler, an 80-year-old man, died from metastatic hepatocellular carcinoma at Braeside Hospital. He was a forensic patient under Mental Health Act detention after being found not guilty by reason of mental illness of…
61y · Female·multi organ failure due to abdominal sepsis
Lesley Arndell, aged 61, died from multi-organ failure due to abdominal sepsis after undergoing a Whipple's procedure for pancreatic cancer. Key clinical lessons include: (1) patients with previous bariatric surgery requ…
47y · Female·hypoxic encephalopathy and aspiration pneumonia following aspiration of gastric …
Jodie Ann Pearson, aged 47, died from hypoxic encephalopathy and aspiration pneumonia following aspiration of gastric contents during a gastroscopy at Belmont Hospital on 15 February 2016. Critical pre-procedure informat…
27y · Male·multiple organ failure due to the consequences of multiple gunshot wounds to the…
Mahmoud Houri died aged 27 in custody from multiple organ failure, a consequence of gunshot wounds sustained in 2002. The inquest examined whether appropriate care was provided on 21 August 2008 when he presented with vo…
56y · Male·Hypoxia and cardiac arrest with contributing conditions of Ischaemic Heart Disea…
A 56-year-old man with diabetes, ischaemic heart disease, morbid obesity, and an implanted defibrillator underwent minor toe debridement surgery. The anaesthetist failed to conduct an adequate pre-operative assessment, u…
27y · Male·Loss of airway control and blockage due to aspiration from complications of a sm…
Dr R., a 27-year-old physician with cystic fibrosis, died from aspiration and airway blockage secondary to a small bowel obstruction whilst under dual respiratory-surgical care at Westmead Hospital. Critical clinical les…
67y · Female·Sepsis as a result of gastric perforation
Margaret Pegum, aged 67, died from sepsis following gastric perforation after an intragastric balloon (IGB) procedure for weight loss. She had undergone fundoplication for hiatus hernia in 2012. Despite prior gastric sur…
90y · Male·Complications arising from a gastrointestinal obstruction; incarcerated inguinal…
William MacDonald, a 90-year-old prisoner, died from complications of gastrointestinal obstruction caused by an incarcerated inguinal hernia. He presented to Prince of Wales Hospital with severe abdominal pain, nausea, a…
70y · Female·Hypoxic/Ischaemic Encephalopathy consequent upon Cardiorespiratory Arrest and Co…
Beverly Ann Murphy, 70, underwent hysterectomy for endometrial carcinoma on 2 April 2008 at Royal Hospital for Women. The complex surgery was complicated by iatrogenic small bowel perforations. Post-operatively, wound de…
Male·Faecal peritonitis due to perforated diverticulum
Michael Sutherland presented to Bega Hospital Emergency Department on 2 March 2006 with severe abdominal pain from diverticulitis with bowel perforation. Dr B., the attending Career Medical Officer, formed an unfounded b…
68y · Male·Complications following colon surgery on a background of cirrhosis of the liver;…
Ian Donald Patience, 68, died on 10 June 2007 from complications following colon surgery in the setting of cirrhosis. He underwent right hemicolectomy at Sydney South West Private Hospital on 31 May 2007 for colorectal c…
78y · Female·sepsis and aspiration with metabolic dysfunction as a result of mechanical small…
Joan Dennison, aged 78, was discharged from Shellharbour Hospital emergency department on 16 November 2007 with a misdiagnosis of constipation, despite clinical and imaging features diagnostic of small bowel obstruction …
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