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NSWhospital2020-02-28

Inquest into the death of Peter ROBIN

56y · Male·Pulmonary embolism with deep vein thrombosis an antecedent cause; coronary arter…

Peter Robin, a 56-year-old man with a medical history of hypercholesterolaemia, hypertension, obesity, and depression, underwent elective dental surgery on 28 October 2015 to remove four wisdom teeth and resect a cyst. H…

oral and maxillofacial surgeryanaesthesiacommunicationsystemoxycodone
TAShospital2019-09-30

Coroner's Finding: Frith, Aaron Douglas

36y · Male·pulmonary embolism due to right deep vein thrombosis following repair of rupture…

Aaron Frith, a 36-year-old man with obesity and hypertension, sustained a ruptured right Achilles tendon on 28 August 2018. He underwent surgical repair on 15 September 2018 and was discharged on aspirin prophylaxis. He …

orthopaedic surgeryemergency medicinediagnosticsystemaspirin
QLDhospital2019-09-03

Mr DAC - Non-inquest findings

51y · Male·Sepsis due to or as a consequence of right lower limb necrotising fasciitis due …

A 51-year-old man with metastatic renal cell carcinoma died from sepsis following necrotising fasciitis of the lower limb, which developed after a pseudo-aneurysm complication from coronary angiography. Key clinical less…

cardiologyvascular surgerydiagnosticproceduralpazopanib
NSWhospital2019-03-22

Inquest into the death of Patrick THOMAS

52y · Male·Intestinal failure/sepsis arising from venous ischemia as a result of superior m…

Patrick Thomas, a 52-year-old man, died from intestinal failure and sepsis following an accidental division of the superior mesenteric vein (SMV) during laparoscopic surgery for colon cancer at Kareena Private Hospital o…

colorectal surgeryintensive carecommunicationsystem
TAScommunity2019-03-08

Coroner's Finding: Paraskevas, Odissefs

56y · Male·pulmonary thromboembolism due to left deep vein thrombosis

A 56-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis. He presented to his GP on 20 January 2017 with persistent dyspnoea and chest pain following a 22-hour flight to Greece and respirat…

general practicecardiologydiagnosticdelay
VIChospital2018-11-19

Finding into death of Robert Humphreys

71y · Male·Aspiration in setting of paralytic ileus in patient in convalescent phase of abd…

A 71-year-old man died from aspiration complicating prolonged paralytic ileus on postoperative day 9 following open abdominal aortic aneurysm repair. Despite clinical signs of persistent ileus (vomiting, abdominal disten…

vascular surgeryintensive carediagnosticdelayatropine
NSWhospital2018-10-22

Inquest into the death of Sandra Cree

71y · Female·Ruptured abdominal aortic aneurysm, with coronary artery atherosclerosis contrib…

Sandra Cree, a 71-year-old woman, died from a ruptured abdominal aortic aneurysm (AAA) after undergoing an elective endovascular repair procedure in Brisbane. She presented to a remote hospital (Lightning Ridge Multi-Pur…

emergency medicinevascular surgerydiagnosticcommunicationgentamicin
TAShospital2018-09-21

Coroner's Finding: Patrick, Robert David

65y · Male·ruptured abdominal aortic aneurysm

A 65-year-old man with recently diagnosed small cell lung cancer presented to a rural hospital with acute back pain. He had a known abdominal aortic aneurysm (73mm) identified on staging scans. The attending nurse docume…

emergency medicinegeneral practicediagnosticcommunicationmorphine
TAShospital2018-05-30

Coroner's Finding: Forward, Trudi Maree

53y · Female·sepsis and multiple organ failure attributable to infarction/necrosis of small b…

A 53-year-old woman with Type II diabetes, obesity, and Korsakoff dementia presented with acute severe abdominal pain from superior mesenteric artery (SMA) thrombosis at 3:00 AM on 19 August. Despite elevated lactate, me…

emergency medicinegeneral surgerydiagnosticdelay
VIChome2017-12-04

Finding into death of Leigh Thomas Aiple

31y · Male·Pulmonary thromboembolism

A 31-year-old man with obesity (BMI 40.2) and sleep apnoea underwent extensive cosmetic surgery in Malaysia (liposuction, abdominoplasty, chest lipectomy, and subsequent facial procedures) across two operations within fi…

plastic and reconstructive surgerygeneral surgerydiagnosticmedicationenoxaparin
TAShospital2017-05-19

Coroner's Finding: Smith, James Maurice

38y · Male·haemopericardium (pericardial tamponade) due to aortic dissection

James Maurice Smith, 38-year-old male, died from haemopericardium due to aortic dissection. He presented to ED on 9 June 2015 with severe back and abdominal pain, elevated lactate, and neurological symptoms suggesting va…

emergency medicinegeneral surgerydiagnosticcommunicationondansetron
WAhospitalPodcast2017-05-03

Inquest into the Death of Edith Catherine BEE

80y · Female·Gas embolism complicating surgical repair of an atherosclerotic aortic aneurysm …

An 80-year-old woman with multiple comorbidities (COPD, renal impairment, cardiac disease) underwent complex endoluminal repair of a thoracoabdominal aortic aneurysm at a private hospital. The procedure required use of C…

vascular surgerygeneral surgeryproceduralsystem
QLDhospital2016-11-04

Neitsch, Horst - non-inquest findings

77y · Male·Stroke; cardiogenic shock; severe aortic stenosis with three vessel coronary art…

Mr Neitsch, a 77-year-old with severe aortic stenosis, peripheral vascular disease, and reduced left ventricular function, underwent elective coronary angiography at Princess Alexandra Hospital on 21 May 2015. The proced…

cardiologyvascular surgeryproceduralcommunicationfurosemide
SAhospital2016-09-29

Coroner's Finding: MCSHANE Robert Ian

66y · Male·Multi-system failure and ischaemic gut after left nephrectomy complicated by mas…

A 66-year-old man died from multi-system failure and ischaemic bowel following laparoscopic left nephrectomy complicated by massive haemorrhage and vascular injury. During surgery for renal carcinoma, the surgeon attempt…

urologyvascular surgeryproceduralsurgical judgment
VIChospital2016-08-18

Finding into death of Susan Bourke

49y · Female·Widespread small and large bowel, splenic and hepatic infarction secondary to se…

Susan Bourke, a 49-year-old woman, died from widespread small and large bowel infarction secondary to severe aortic atherosclerosis causing critical stenosis of the superior mesenteric and coeliac arteries. She presented…

emergency medicineradiologydiagnosticcommunication
VIChospital2016-04-14

Finding into death of Kelly Maree Richards

29y · Female·Exsanguination post tubal ligation procedure

A 29-year-old woman died from exsanguination following an iatrogenic injury during elective laparoscopic tubal ligation at a regional hospital. A vascular injury to the right external iliac artery occurred during the pro…

general surgerygynaecologyproceduralcommunicationpacked red blood cells
TAShome2016-01-28

Coroner's Finding: Atkinson, James Robert

80y · Male·Subdural haematoma from closed head injury sustained in a fall at his residence

James Robert Atkinson, aged 80, died from subdural haematoma sustained in a fall at his home in Tasmania on 11 July 2014, four days after sustaining another head injury. He had mixed Alzheimer's and vascular dementia dia…

general practiceemergency medicine
VIC2015-05-29

Finding into death of Ignac Lecek

68y · Male·Ischaemic small and large intestine complicating cardiogenic shock in the settin…

Ignac Lecek, 68, with hypertension and gout, collapsed in custody and died of ischaemic bowel complicated by cardiogenic shock in the setting of ischaemic heart disease. He complained of feeling ill on 2 October while in…

emergency medicinevascular surgerycommunicationsystemdiazepam
VIChospital2014-08-27

Finding into death of Robert Vivian Hawkins

55y · Male·Multi-system failure complicating intra-operative haemorrhage due to inadvertent…

Robert Vivian Hawkins, a 55-year-old man, died from multi-system failure following inadvertent ligation of the superior mesenteric artery (SMA) during laparoscopic nephrectomy for renal cell carcinoma. Dr L. misidentifie…

urologygeneral surgerydiagnosticprocedural
VIChome2014-05-15

Finding into death of Georgia Susan Cheal

31y · Female·Pneumonia; combined drug toxicity (including marijuana), smoking, pathological o…

Georgia Cheal, a 31-year-old with complex medical history including chronic pain, major depression, and obesity, died from pneumonia exacerbated by combined drug toxicity from multiple prescription medications, cannabis,…

general practicepsychiatrycommunicationsystemoxycodone

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