80y · Female·peritonitis due to sigmoid resection margin leak following extended right hemico…
…curred: a PET scan in May 2010 showed a colonic mass, but respiratory physician Dr M. failed to arrange colonoscopy, leaving this to GP Dr C. who did not follow up. Diagnosis was delayed five months. Post-operatively, p…
61y · Female·respiratory failure secondary to advanced malignancy
…t metastatic disease developed with ascites. The Guardianship Board granted section 32 powers to enable colonoscopy and stenting, but Ms Bellocco deteriorated rapidly. A case conference on 9 October 2009 determined pall…
82y · Male·Cardiomegaly, myocardial fibrosis and ischaemic coronary artery disease in the c…
An 82-year-old man with extensive comorbidities underwent colonoscopy with argon plasma coagulation (APC) for bleeding angiodysplasia. Prolonged activation intervals during …
39y · Male·Complications of large bowel pseudo-obstruction
…tion, and bowel obstruction, requiring intubation and ICU care. Despite aggressive management including colonoscopy and laparotomy, he deteriorated from ischaemic bowel changes and multi-organ failure. The coroner found…
76y · Male·small bowel obstruction in the setting of terminal metastatic neuro-endocrine tu…
… family history of bowel cancer. Despite nursing staff appropriately identifying need for GP review and colonoscopy, administrative failures prevented proper waitlisting. Expert oncologists confirmed earlier diagnosis (…
86y · Male·Septic shock secondary to urosepsis
Robert Avery, 86, was admitted to Valley Private Hospital for colonoscopy to investigate constipation. After the procedure was cancelled due to respiratory concerns, he was mana…
58y · Female·lymphangitic carcinomatosis leading to hypoxaemic respiratory failure and cardia…
…n presenting with weight loss, anorexia, and unexplained shortness of breath, underwent gastroscopy and colonoscopy at a private hospital to investigate suspected gastric pathology. She had hypoxaemia (oxygen saturation…
40y · Male·large bowel obstruction complicating disseminated carcinoma of rectum
A 40-year-old male died in prison custody from large bowel obstruction complicating disseminated rectal carcinoma. He had been diagnosed with adenocarcinoma in 2004, treated with radiotherapy and chemotherapy, with progr…
72y · Male·pneumonia in a man with metastatic colon cancer
Lawrence Noyes was a 72-year-old man serving a prison sentence who presented with metastatic colon cancer. He underwent surgery including palliative bypasses and later a gastrostomy and jejunostomy for nutritional suppor…
44y · Male·aspiration and intellectual disability
Andrew Wilson, a 44-year-old man with intellectual disability, epilepsy, asthma, and severe scoliosis, died from aspiration in a community residential unit. He had been prescribed a laxative and enema for constipation af…
57y · Male·Complications of congenital rubella (palliated)
Russell Aldridge, aged 57, died of complications from congenital rubella at his SDA care home. He had complex medical needs including intellectual disability, deafness, blindness, dysphagia, epilepsy, and recent diagnosi…
53y · Male·metastatic carcinoma of the rectum (operated)
Paul Eugene Anker, a 53-year-old prisoner, died from metastatic rectal carcinoma at the Queen Elizabeth Hospital. He had been appropriately diagnosed with bowel cancer in 2016 whilst in custody and underwent surgery, che…
64y · Male·Complications of advanced rectal carcinoma
David Ronald Thompson, a 64-year-old man with severe intellectual disability and complex medical needs, died from complications of advanced rectal carcinoma. He resided in specialist disability accommodation and had been…
78y · Female·Acute gastrointestinal haemorrhage
Ms Beverly Davidge, a 78-year-old woman with intellectual disability living in residential care, died from acute gastrointestinal haemorrhage in hospital. She presented initially with haematemesis and melaena on 11 Novem…
57y · Male·Bronchopneumonia complicating metastatic and locally advanced primary adenocarci…
A 57-year-old male prisoner died from bronchopneumonia complicating metastatic lung adenocarcinoma. He was diagnosed with stage IV lung cancer in February 2016 while incarcerated and opted for palliative care, declining …
78y · Male·metastatic malignancy (unknown primary) with contributing right-sided heart fail…
…ormone therapy but liver disease progressed, indicating a different primary source (possibly bowel). No colonoscopy or liver biopsy was performed to identify the primary cancer. Expert opinion suggests earlier investiga…
55y · Male·Complications of fibrosing alveolitis
John Majinski, a 55-year-old prisoner with severe fibrosing alveolitis, pulmonary hypertension, diabetes, and recurrent infections, died from complications of his lung disease while incarcerated. He received intensive me…
68y · Male·Abnormal heart rhythm (arrhythmia) precipitated by coronary atherosclerosis and …
John Martin Heywood, a 68-year-old prisoner, died of natural causes (arrhythmia precipitated by coronary atherosclerosis and phaeochromocytoma) while in custody at the Princess Alexandra Hospital Secure Unit. He had been…
49y · Male·Complications in association with advanced gastric malignancy
Roy Charles Gilbert, a 49-year-old prisoner, died from complications of advanced gastric adenocarcinoma with metastatic disease. He presented with gastrointestinal symptoms from 2009 onwards but initially declined invest…
62y · Male·bronchopneumonia in a man receiving terminal palliative care for metastatic carc…
Robin David Macartney, a 62-year-old prisoner serving a life sentence for murder, died from bronchopneumonia secondary to metastatic colon cancer. He was diagnosed with sigmoid colon cancer in December 2006 but refused s…
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