14 results
70y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …
Ali Djawas, a 70-year-old Indonesian-born man with comorbidities (hypertension, diabetes, COPD), underwent elective right hemicolectomy on 13 March 2017 for a suspicious ileo-caecal lesion. Biopsies were benign, CT imagi…
77y · Male·sepsis due to retroperitoneal collection after biliary stent insertion on a back…
A 77-year-old Aboriginal man died from sepsis following a percutaneous transhepatic cholangiography (PTC) procedure that perforated his duodenum. Critical failures included: delayed diagnosis and treatment of peritonitis…
67y · Male·multi-organ failure due to septic shock consequent on faecal peritonitis due to …
David Fensom, 67, underwent elective fundoplication for hiatus hernia and reflux on 21 September 2010. He developed severe right-sided abdominal pain post-operatively. A laparoscopy on 8 October misinterpreted findings a…
75y · Female·septic complications following surgical resection of duodenal ampullary adenoma
A 75-year-old woman died of sepsis from bile leaking into her abdomen after elective surgery to remove a pre-malignant tumour adjacent to the bile duct. The coroner found multiple preventable failures: inadequate pre-ope…
28y · Male·Multiple injuries following a motor vehicle crash while concurrently suffering f…
A 28-year-old Aboriginal man died from severe traumatic brain injury following a high-speed motor vehicle crash. He was unlicensed, driving another's vehicle, and had a blood alcohol level of 0.205% (over 3x legal limit)…
17y · Male·pneumonia and respiratory failure associated with choreoathetoid cerebral palsy
A 17-year-old Indigenous male with severe choreoathetoid cerebral palsy, feeding difficulties, and swallowing dysfunction died of pneumonia and respiratory failure in ICU. He had missed lunch medications (Baclofen and Ga…
65y · Male·peritonitis and necrosis of the bowel following a ruptured appendix
A 65-year-old prisoner with severe triple-vessel coronary artery disease died from peritonitis and bowel necrosis following an appendectomy. Initial surgery for perforated appendicitis was technically difficult but compe…
82y · Female·acute peritonitis, ruptured bowel and incarcerated bowel herniation
An 82-year-old woman admitted with bowel obstruction recovered well initially but suffered a preventable fall in the radiology department when left unattended with heavy IV pumps on her wheelchair, fracturing her hip. Af…
58y · Female·acute peritonitis, which led to the development of acute septicaemia following a…
A 58-year-old woman died from acute peritonitis and sepsis following surgery for duodenal diverticulum. Initial elective surgery on 4 March 2008 was technically successful, but the patient deteriorated with suspected com…
49y · Male·Acute bronchopneumonia as a consequence of recent intracranial and intra-cerebra…
Peter Raymond Jacobs, a 49-year-old Aboriginal man with severe cirrhosis and chronic alcohol abuse, was apprehended by police on 5 April 2008 for intoxication. He fell twice before custody (hitting his head at Town Hall …
28y · Male·hypovolemia secondary to haemorrhage from operative exploration of multiple stab…
A 28-year-old Aboriginal male died from hypovolemic shock following operative exploration of multiple stab wounds to the thigh. The death was preventable. Critical failures included: delayed surgery from Friday to Saturd…
33y · Male·Multiple injuries sustained in a single vehicle crash, complicated by acalculous…
Jason Donald, a 34-year-old Aboriginal male, was involved in a high-speed police pursuit following allegations of breaching a domestic violence order. He was driving erratically and intoxicated (BAC 0.285) when police ac…
57y · Male·Multiple organ failure in consequence of peritonitis resulting from complication…
Robert Douglas Dalgleish died from multiple organ failure due to peritonitis resulting from complications of gastric banding surgery. He presented to the ED on 18 July 2002 with abdominal pain and vomiting. Dr Bodnar app…
41y · Female·secondary haemorrhage following gastric banding surgery
A 41-year-old enrolled nurse died from secondary haemorrhage eight days after laparoscopic gastric banding surgery in Darwin. She attended ED on 18 February with post-operative pain; Dr McNair discharged her after two ho…
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