205 results
62y · Female·Hypovolaemic and cardiogenic shock (hysterectomy) in the context of cardiomegaly…
A 62-year-old woman with significant comorbidities (cirrhosis, cardiomegaly, thrombocytopenia, chronic kidney disease, COPD) died from hypovolaemic and cardiogenic shock during elective total laparoscopic hysterectomy fo…
85y · Male·Incised wounds to the wrist
An 85-year-old man with myelodysplasia and severe hip pain from an ischiorectal abscess died from incised wrist wounds sustained in a nursing home while in palliative care. He had expressed wishes to die, discussed eutha…
75y · Female·Complications including acute pancreatitis and refractory intra-abdominal sepsis…
Lee Milcherdy, 75, died from complications including acute pancreatitis and refractory intra-abdominal sepsis following an unnecessary ERCP procedure. An MRCP scan on 12 October 2018 showed no gallstone, making the plann…
57y · Male·Sepsis from ischemic bowel due to superior mesenteric artery thrombus
Trevor Peterson, a 57-year-old with chronic gut ischemia, underwent mesenteric artery stenting in February 2020. Discharge instructions emphasising dual antiplatelet therapy (DAPT) were not clearly communicated to the va…
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…
77y · Female·Haemoperitoneum following cholecystectomy
A 77-year-old woman died from haemoperitoneum (intra-abdominal bleeding) three days after elective laparoscopic cholecystectomy. Bleeding from the left inferior epigastric artery was a recognised surgical complication bu…
85y · Female·Staphylococcus bacteremia complicating multiple injuries sustained in a motor ve…
An 85-year-old woman sustained multiple serious injuries (bilateral rib and pelvic fractures, thoracic spine fractures) in a motor vehicle collision on 20 June 2018. She was treated with ICU admission, induced coma, and …
77y · Male·shock due to bowel ischaemia following massive blood loss due to bleeding of the…
Anthony George Bennett, a 77-year-old man with significant comorbidities including ischaemic heart disease, atrial fibrillation, peripheral vascular disease, and end-stage kidney disease, died from shock due to bowel isc…
76y · Female·Undetermined (natural causes)
HJ, a 76-year-old woman with chronic psychotic disorder and paranoid delusions, presented with abdominal pain, vomiting, and small bowel obstruction. Imaging revealed bilateral adnexal masses. Due to her lack of insight …
63y · Male·metastatic rectal carcinoma
Jeremy Scott, a 63-year-old prisoner, died from metastatic rectal carcinoma on 3 July 2017. From 2015 onwards, he reported rectal and anal symptoms including pain, bleeding, and palpable masses, which were repeatedly att…
67y · Male·acute gastrointestinal haemorrhage complicating peptic ulcer of the duodenum wit…
A 67-year-old man died from acute gastrointestinal haemorrhage from a duodenal ulcer following complex post-operative complications from laparoscopic Hartmann's procedure for diverticulitis. Key clinical lessons: (1) Ear…
Female·multi-organ failure
Mrs M died from multi-organ failure following recurrent intra-abdominal sepsis and surgical complications after endoscopic duodenal perforation in June 2019. During resection of a duodenal adenoma, perforation occurred r…
56y · Male·Internal blood loss, complications arising from laparoscopic cholecystectomy
Barry Brown, a 56-year-old man, died from internal bleeding after laparoscopic cholecystectomy due to critical systemic failures in post-operative care and diagnosis. Following hypotension at 7:30pm, nursing staff failed…
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·acute myocardial ischaemia due to coronary atherosclerosis
Mr Wade, aged 80, died from acute myocardial infarction following knee surgery. On postoperative day 3, he developed chest symptoms, elevated troponin, and hypoxia. An ECG was performed showing acute anterior myocardial …
94y · Female·Complications of metastatic lobular carcinoma of the breast in a woman with deme…
A 94-year-old woman with advanced dementia and metastatic breast cancer died from complications of her malignancy. She presented repeatedly with vomiting due to duodenal obstruction from metastatic tumour, but this was n…
68y · Male·surgical complications following laparoscopic cholecystectomy for cholecystitis,…
Cyril Churchill, a 68-year-old man with multiple comorbidities, died from surgical complications after laparoscopic cholecystectomy for acute cholecystitis. Postoperatively, he developed profound hypotension. The treatin…
68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…
Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mi…
51y · Female·peritoneal sepsis with multiple organ failure due to perforation of bowel by for…
A 51-year-old woman with intellectual disability and schizoaffective disorder died from peritoneal sepsis and multiple organ failure caused by bowel perforation from a wooden stick. The stick entered her body via her vag…
51y · Female·community acquired pneumonia
Louise Kitty Whiskey, a 51-year-old Aboriginal woman with chronic alcohol misuse, cirrhosis, and recurrent respiratory infections, died from community-acquired pneumonia at Royal Adelaide Hospital. She was admitted on 23…
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