Coronial

146 results for abdominal CT

NSWhospital2018-02-27

Inquest into the death of Michaela Perrin

26y · Female·sepsis

…sia alone. When Michaela returned on 21 October with obvious signs of sepsis (fever 39.3°C, severe pain, abdominal swelling), Dr P. finally recognised possible infection but kept this assessment undisclosed. Although an…

obstetricsemergency medicinediagnosticcommunicationceftriaxone
VIChospital2026-04-16

Finding into death of Damien Mark Stone

53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures

Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…

emergency medicineneurologydiagnosticcommunicationoxycodone
VIChospital2021-02-26

Finding into death of Ian Fraser

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…

respiratory medicinecardiothoracic surgerymedicationsystemapixaban
NThospital2022-01-25

Inquest into the death of Josef Lear

80y · Male·metastatic oesophageal cancer

Josef Lear, an 80-year-old prisoner, died of metastatic oesophageal cancer at the Royal Darwin Hospital Hospice on 7 March 2021. He presented with progressive dysphagia, cough, and weight loss in mid-2020, which was appr…

oncologygastroenterologycommunicationsystemibuprofen
VIChospital2020-07-16

Finding into death of Lydia Maxfield

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

Lydia Maxfield, 85, died 5 days after elective left total knee replacement at a private hospital from multisystem failure due to ischaemic heart disease and ischaemic bowel. Critical clinical lessons: (1) Multiple abnorm…

orthopaedic surgeryanaesthesiacommunicationsystemondansetron
QLDhospital2019-09-05

Mrs MDF - Non-inquest findings

76y · Female·multisystem organ failure due to or as a consequence of ischaemic small intestin…

A 76-year-old woman presented to hospital with abdominal pain and was found on CT scan to have ischaemic colitis with signs of profound shock. The Consultant Sur…

surgeryintensive carediagnosticcommunicationtramadol
VIChospital2017-11-09

Finding into death of Emma Kate McGrath

19y · Female·Meningococcal septicaemia

…icaemia caused by the W strain after presenting to the ED with a 12-hour history of vomiting, diarrhoea, abdominal pain and fever. The atypical presentation of gastrointestinal symptoms rather than classic meningeal sig…

emergency medicineintensive careparacetamol
VIChospital2016-09-15

Finding into death of Bernas Hasibuan

50y · Male·gastrointestinal haemorrhage; haemorrhage from cystic artery post laparoscopic c…

A 50-year-old man died from gastrointestinal haemorrhage involving both a cystic artery and duodenal defect following laparoscopic cholecystectomy. Over five days post-surgery, he developed repeated episodes of hypotensi…

general surgeryintensive carediagnosticcommunication
WAAugust 2024

Inquest into the Death of Robert Allan EXELL

55y · Male·Complications of liver cirrhosis and hepatocellular carcinoma in a man with mult…

Robert Exell, a 55-year-old Aboriginal man, died from complications of liver cirrhosis and hepatocellular carcinoma while in custody. He had chronic hepatitis C and alcohol-related liver disease since at least 2012. Key …

hepatologygastroenterologydelaysystemmorphine
VIChospital2012-08-24

Finding into death of Cameron Yeates

31y · Male·Acute colonic pseudo-obstruction; death certificate amended to 'unascertained' -…

Cameron Yeates, a 31-year-old man with intellectual disability (IQ 64) and longstanding gastrointestinal issues, died from acute colonic pseudo-obstruction with underlying malnourishment. Key clinical lessons: (1) severe…

gastroenterologygeneral practicecommunicationsystemwarfarin
NSW2018-10-26

Inquest into the death of Mahmoud Houri

27y · Male·multiple organ failure due to the consequences of multiple gunshot wounds to the…

…est examined whether appropriate care was provided on 21 August 2008 when he presented with vomiting and abdominal pain, which led to emergency surgery revealing a rare small bowel volvulus requiring total bowel resecti…

general surgerygastroenterologymetoclopramide
QLDhospital2013-04-19

Brockel, Ronald James

64y · Male·aspiration pneumonia following insertion of a jejunostomy tube

Ronald Brockel, a 64-year-old with cerebral palsy, oropharyngeal dysphagia, and recurrent aspiration pneumonia, underwent insertion of a feeding jejunostomy tube (FJT) on 23 December 2004 to bypass his stomach and improv…

general surgerygastroenterologyproceduraldiagnosticomeprazole
QLDhospitalPodcast2011-10-07

Saunders, Ryan Charles

2y · Male·Group A Streptococcal toxic shock syndrome which probably originated in the thro…

Ryan Saunders, a 2-year-old boy, died from Group A Streptococcal toxic shock syndrome after a 72-hour presentation with fever, pain, and systemic illness. Initial GP care was appropriate given the presentation and diagno…

paediatricsemergency medicinediagnosticcommunicationparacetamol
NSWhospital2026-03-19

Inquest into the death of Eve Brown

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

…oms and was admitted to Lightning Ridge Multi-Purpose Centre despite clinical features (severe vomiting, abdominal pain, elevated temperature) warranting transfer to Dubbo Base Hospital for CT imaging to exclude serious…

emergency medicinegeneral practicediagnosticcommunicationceftriaxone
VIChospital2019-08-01

Finding into death of Tyla Jade Hovenbitzer

18y · Female·Multiorgan failure complicating malnutrition in a female with liver cirrhosis, o…

An 18-year-old female with Down syndrome, autism spectrum disorder, and severe intellectual disability died from multiorgan failure complicating severe malnutrition, non-alcoholic fatty liver disease, and obesity. She pr…

paediatricsgeneral practicesystemdelaytemazepam
WAhospital2012

Inquest into the Death of Keogh

38y · Female·Pulmonary Thromboembolism

Kellie Anne Keogh, 38, died from pulmonary thromboembolism on 10 November 2008 after complex pancreatic surgery. She had nephrotic syndrome with decreased anti-thrombin III levels, initially presenting with suspected DVT…

general surgeryintensive carecommunicationdelaywarfarin
NSWhospital2023-03-09

Inquest into the death of William Edmunds

79y · Male·complications of peritonitis

… error went undetected for 8 days despite clinical signs (absent stomal output, high nasogastric output, abdominal distension). Dr S. failed to order imaging despite concerning clinical features and did not review the p…

general surgeryintensive careproceduraldiagnosticmorphine
NSWhospital2022-03-25

Inquest into the death of Anthony Barrett

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…

orthopaedic surgeryvascular surgerycommunicationdiagnosticclopidogrel
QLDhospital2012-12-06

McNaught, Judith

69y · Female·Septic shock due to biliary peritonitis as a consequence of laparoscopic cholecy…

A 69-year-old woman died of septic shock following bile leak complications after laparoscopic cholecystectomy. Critical failures included: (1) inappropriate transfer to low-dependency unit on post-op day 1 despite consul…

surgeryanaesthesiadiagnosticmedicationmorphine
WAhospital2023-11-02

Inquest into the Death of Bradley James Raymond STINSON

66y · Male·Cardiac arrhythmia in a man with arteriosclerotic cardiovascular disease, pulmon…

Bradley Stinson, a 66-year-old prisoner with a long history of heavy smoking and alcohol use, died from cardiac arrhythmia in the setting of arteriosclerotic cardiovascular disease, pulmonary thromboembolism, and metasta…

palliative careoncologyproceduralsystemoxycodone
1678

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