Coronial

75 results for small bowel obstruction

NSWhospital2023-03-09

Inquest into the death of William Edmunds

79y · Male·complications of peritonitis

A 79-year-old man with multiple comorbidities presented with a perforated bowel requiring emergency Hartmann's procedure. The operating surgeon, Dr L.-Ming Schmidt, made a catastrophic s…

general surgeryintensive careproceduraldiagnosticmorphine
QLDaged care2017-05-03

Biffin, Albert Eric

86y · Male·Cardiac arrest triggered by electrolyte imbalance and sepsis secondary to compli…

… comorbidities died in a low-care nursing home from complications of an incarcerated umbilical hernia with bowel ischaemia, sepsis, and cardiac arrhythmia. His GP examined him briefly (10-15 minutes) without reviewing n…

general practicesurgerydiagnosticcommunicationmacrogol
WAmental health- 11 April 2014

Inquest into the Death of Ritchie GORDON

49y · Male·unascertainable; possible explanations include epileptic seizure, cardiac arrhyt…

…f patients on clozapine—particularly regarding cardiac complications and metabolic effects—and appropriate bowel management in patients with psychiatric conditions affecting fluid and dietary intake.

psychiatryforensic medicineclozapine
QLDhospital2007-08-26

Fitter, Maureen

60y · Female·Cardiac tamponade due to ruptured heart due to total parenteral nutrition due to…

…used by TPN fluid leaking into the pericardium through a PICC line inserted to provide nutrition following bowel surgery. The PICC line was inserted under image intensification with appropriate technique and placement a…

colorectal surgerygastroenterologytotal parenteral nutrition
VIChospital2020-07-16

Finding into death of Lydia Maxfield

85y · Female·Multisystem failure complicating ischaemic heart disease and ischaemic bowel in …

…ee replacement at a private hospital from multisystem failure due to ischaemic heart disease and ischaemic bowel. Critical clinical lessons: (1) Multiple abnormal vital signs (low oxygen saturation, hypotension) occurri…

orthopaedic surgeryanaesthesiacommunicationsystemondansetron
NThospital2012-11-16

Inquest into the death of Yong Lam Chai

52y · Male·Left upper lobe collapse/bronchopneumonia and haemorrhagic pleural effusion seco…

Yong Lam Chai, a Malaysian national serving a life sentence for drug importation, died from advanced metastatic lung cancer with pleural effusion at Royal Darwin Hospital in July 2011. The coroner found that care provide…

oncologyrespiratory medicine
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
VIChospital2012-03-02

Finding into death of Elsa Harrington

45y · Female·Multisystem organ failure secondary to acute liver failure associated with parac…

… liver failure secondary to paracetamol toxicity in November 2002. She was admitted post-hysterectomy with bowel obstruction and underwent adhesion surgery. Following surgery, she received therapeutic doses of paracetam…

general surgerycardiologydiagnosticcommunicationparacetamol
SAhospitalPodcast2025-07-31

Coroner's Finding: Panella, Anna Vincenza and Skeffington, Bernard Anthony and Jessett, Graham Henry

Unknown·Panella: pulmonary thromboembolism due to left calf deep vein thrombosis; Skeffi…

Three South Australians died following extended waits on ambulance ramps outside metropolitan hospitals. Anna Panella (76) died from pulmonary thromboembolism; Bernard Skeffington (89) died from aspiration pneumonia afte…

emergency medicinecardiologycommunicationsystem
WAhospital2014-08-29

Inquest into the Death of Daniel LAHENGKING

66y · Male·multiple organ failure associated with the combined effects of complications of …

Daniel Lahengking, a 66-year-old Indonesian visiting family in Esperance, was diagnosed with rheumatoid arthritis by locum GP Dr H. and prescribed methotrexate 5-10mg daily, a grossly excessive dose (normal: 7.5-20mg wee…

general practicepharmacydiagnosticmedicationmethotrexate
WAhospital2021-11-29

Inquest into the Death of Miss T (Name Subject to Suppression Order)

16y · Female·acute abdominal obstruction secondary to adhesions associated with severe pelvic…

A 16-year-old Aboriginal girl died on Christmas Day 2016 from acute abdominal obstruction secondary to severe pelvic inflammatory disease caused by untreated gonorrhoea. Miss T presented to the…

emergency medicinegeneral practicediagnosticsystemcannabis
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…

…with an inferior mesenteric vein graft and transfer to Sutherland Hospital ICU, the graft occluded and his small bowel became non-viable. Critical failures included: (1) the surgeon's erroneous advice that the death nee…

colorectal surgeryintensive carecommunicationsystem
TAShospital2017-03-20

Coroner's Finding: Bird, Heather Mary

66y · Female·retroperitoneal haemorrhage due to anticoagulation following right cerebrovascul…

A 66-year-old woman died from retroperitoneal haemorrhage following anticoagulation for stroke caused by intra-arterial central venous catheter placement. The catheter was mistakenly inserted into the right carotid arter…

anaesthesiarehabilitation medicinediagnosticproceduralenoxaparin
NSWhospital2026-03-19

Inquest into the death of Eve Brown

42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…

…ial diagnoses. Critical failures included: (1) failure to document and investigate differential diagnoses (bowel obstruction, pancreatitis, diverticulitis); (2) no vital signs recorded for 12 hours despite yellow-zone t…

emergency medicinegeneral practicediagnosticcommunicationceftriaxone
WAhospital2022-06-23

Inquest into the Death of Lee MILCHERDY

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…

gastroenterologygeneral surgerycommunicationdiagnostic

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