Coronial

58 results for bowel perforation

VIChospital2016-07-14

Finding into death of Ross Albert Butler

67y · Male·Faeculent peritonitis due to perforation of a sigmoid volvulus

…onservative management was continued, but he deteriorated and died from faeculent peritonitis secondary to bowel perforation. Critical clinical lessons include: (1) comprehensive abdominal assessment documentation by nu…

general surgeryemergency medicinecommunicationdocumentationmorphine
ACThospital2024-09-16

Inquest Into The Death Of Sharyn Kaine

73y · Female·Multi organ failure due to adhesions related bowel perforation (surgically treat…

Sharyn Kaine, a 73-year-old woman, died from multi-organ failure due to adhesions-related bowel perforation and paracetamol-induced liver failure. She was prescribed intravenous paracetamol 1g four time…

general surgeryanaesthesiamedicationtranscriptionparacetamol
WAhome2026-02-23

Inquest into the Death of Child MML

11y · Male·Bronchopneumonia and small bowel necrosis with perforation, in a boy with multic…

…epartment of Communities, who provided exemplary 24-hour care. He died at age 11 from bronchopneumonia and bowel perforation, natural consequences of his severe disability. The coroner found the care provided by his gra…

neurologypaediatricscommunicationsystem
VICcommunity2014-12-08

Finding into death of Gerard Alexander Tibballs

66y · Male·Peritonitis secondary to bowel perforation from small bowel obstruction caused b…

…esented with vomiting and diarrhoea. His GP, Dr D., ordered an abdominal X-ray on 23 June 2010, suspecting bowel obstruction but did not mark it urgent. The radiologist, Dr T., identified a small bowel obstruction and a…

general practiceradiologycommunicationdelaymetoclopramide
TAShospital2016-06-27

Coroner's Finding: Mr P

64y · Male·Small bowel infarction due to a volvulus owing to adhesions in the small intesti…

…tal's Emergency Department in October 2012 with severe central abdominal pain. The ED consultant diagnosed bowel obstruction but failed to consider critical complications such as strangulation, perforation, and peritoni…

emergency medicinegeneral surgerydiagnosticdelay
QLDhospital2007-12-07

Burgen, Deborah Denise

49y · Female·Intra-abdominal haemorrhage, septic and haemorrhagic shock as a result of a lapa…

… died from intra-abdominal haemorrhage complicated by septic shock following delayed emergency surgery for bowel obstruction. She attended the emergency department six times over eleven days with identical symptoms but …

emergency medicinesurgerydiagnosticdelayparacetamol/codeine
SAhospital2005-06-03

Coroner's Finding: SORENSEN Ruth Bengta Maria

69y · Female·faecal peritonitis due to small bowel obstruction and perforation due to periton…

…diagnosis. She deteriorated rapidly and died at home the next morning from faecal peritonitis due to small bowel obstruction and perforation from peritoneal adhesions. The coroner found the standard of care was seriousl…

emergency medicinesurgerydiagnosticcommunicationprochlorperazine
NSWhospital2019-07-22

Inquest into the death of Nicholas Wells

24y · Male·Peritonitis secondary to a perforation of the small bowel

Nicholas Wells, a 24-year-old man, died from peritonitis secondary to small bowel perforation sustained in a motor vehicle accident. Although he was suspected of having a bowel injury at 1…

emergency medicinesurgerydiagnosticcommunicationmethamphetamine
SAhospital2004-02-13

Coroner's Finding: CUCUK Radomir

38y · Male·multi organ failure secondary to intestinal ischaemia from toxic megacolon relat…

…olectomy. Despite appropriate clinical assessment and timely surgical intervention, he died from ischaemic bowel necrosis. The coroner found no grounds for criticism of medical treatment. However, the case highlights th…

psychiatryemergency medicineclozapine
TASaged care2018-01-29

Coroner's Finding: Ball, Betty Irene

67y · Female·perforated sigmoid volvulus with peritonitis upon a background of spinocerebella…

…rvival. The aged care facility's protocols were inadequate; a new system now provides automatic alerts for bowel inactivity, addressing this systemic weakness.

general practiceemergency medicinedelaysystemparacetamol
VIChospital2023-10-30

Finding into death of BCT

2y · Unknown·Hypoxic-ischaemic encephalopathy following sepsis related to abdominal surgical …

…etic disorder (CAMTA1 mutation) who died from hypoxic-ischaemic encephalopathy following sepsis related to bowel perforation after a percutaneous endoscopic gastrojejunostomy (PEG-J) procedure. Critical failures include…

gastroenterologyradiologydiagnosticcommunicationceftriaxone
NSWhospital2025-08-14

Inquest into the death of Margaret Mariani

88y · Female·Complications of cholecystectomy surgery

…from complications of laparoscopic cholecystectomy for gallstone-induced pancreatitis. An iatrogenic small bowel perforation, likely caused by inadvertent suturing during closure, led to peritonitis and aspiration pneum…

surgerygeneral surgerycommunicationdelayfentanyl
WAhospital

Inquest into the Death of June Valerie LOBBAN

69y · Female·Intra-abdominal sepsis and shock with multi-organ failure following intestinal p…

…ibuted to constipation. A locum RMO appropriately ordered abdominal X-rays showing free air (suggesting perforation), but critical delays occurred: the X-ray was not performed until 24 hours later, results were not comm…

neurosurgerygeneral surgerydiagnosticdelayfentanyl
WAhospital2018-06-14

Inquest into the Death of Anne RZEPCZYNSKI

59y · Female·complications of intra-abdominal sepsis, including multi-organ failure and bowel…

59-year-old woman died from intra-abdominal sepsis, multi-organ failure and bowel perforation following median hepatectomy for cholangiocarcinoma. Key clinical issues included: surgical de…

general surgeryintensive carediagnosticdelayantibiotics
NSWhospital2012-06-14

Beverly ann murphy finding & recommendations 0701 08

70y · Female·Hypoxic/Ischaemic Encephalopathy consequent upon Cardiorespiratory Arrest and Co…

…inoma on 2 April 2008 at Royal Hospital for Women. The complex surgery was complicated by iatrogenic small bowel perforations. Post-operatively, wound dehiscence and bowel obstruction developed, requiring return to thea…

gynaecologyoncologydiagnosticcommunication
SAhospital2001-08-24

Coroner's Finding: GADALETA Saverio

28y · Male·Peritonitis and septic shock complicating perforation of the terminal small bowe…

…worsening condition. He suffered cardiac arrest 5.5 hours after arrival with peritonitis from a perforated bowel caused by a swallowed Coca-Cola bottle lid. Although earlier diagnosis might not have changed outcome give…

emergency medicinegeneral surgerycommunicationdelayparacetamol
WAhospital2005-03-03

Inquest into the Death of Giovanni Bertoncini

72y · Male·acute gangrene of colon with probable perforation along with bowel obstruction a…

…s Day 2002 with acute abdominal pain and vomiting. Over two days, his condition deteriorated but ischaemic bowel disease was not diagnosed until the afternoon of 27 December, by which time it was too late for surgical i…

emergency medicinegeneral medicinediagnosticdelayparacetamol
VIC2013-08-19

Finding into death of TH

2y · Female·Blunt force injury to the abdomen

A two-year-old girl died from blunt force injury to the abdomen, sustaining internal injuries including pancreatic rupture, jejunal rupture, and liver trauma with significant intra-abdominal hemorrhage. Evidence indicate…

paediatric surgeryemergency medicinedelaysystem
TAShospital2021-11-29

Coroner's Finding: Bennett, Anthony George

77y · Male·shock due to bowel ischaemia following massive blood loss due to bleeding of the…

…se, atrial fibrillation, peripheral vascular disease, and end-stage kidney disease, died from shock due to bowel ischaemia following massive blood loss from the left internal iliac artery after elective abdominal aortic…

vascular surgerycardiology
QLDhospital2005-05-04

Robinson, Jacinta Kate

7y · Female·cardiac tamponade due to total parenteral nutrition fluid leakage into the peric…

…arenteral nutrition (TPN) fluid leaking into the pericardial sac via a central venous line inserted during bowel obstruction surgery. Clinical lessons: cardiac tamponade is a rare but life-threatening complication of ce…

paediatric surgeryanaesthesiadiagnosticcommunicationtotal parenteral nutrition

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