75y · Female·Complications including acute pancreatitis and refractory intra-abdominal sepsis…
…m 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 planned ERCP inappropriate. Howe…
63y · Male·Bronchopneumonia in a man with cholangitis due to choledocholithiasis
…llstone obstruction. He presented with weight loss and underwent CT imaging showing gallstones, followed by ERCP on 26 June. Despite initial apparent recovery, he deteriorated on 30 June with sepsis and was admitted to B…
76y · Female·Aspiration pneumonia and cholangitis; obstructive jaundice from intraduct tumour…
…ondary to an obstructive bile duct tumour. She was admitted with obstructive jaundice and sepsis, underwent ERCP procedures for bile duct obstruction and stent insertion. Despite antibiotic therapy and supportive care in…
66y · Male·hepatorenal failure and biliary sepsis complicating common bile duct obstruction
… 2007. Transfer to Royal Adelaide Hospital ICU in April 2007 revealed probable biliary cancer. He underwent ERCP with stent insertion and required ICU support including mechanical ventilation and dialysis. After extubati…
76y · Male·Multiple organ failure due to sepsis with peritonitis and pancreatitis, secondar…
A 76-year-old man died from multiple organ failure following an ERCP procedure for gallstone removal. The procedure itself was appropriate and uneventful. Post-operatively, he …
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…
32y · Male·Complications of acute pancreatitis
… care facility. He had two unsuccessful attempts at surgical intervention (laparoscopic cholecystectomy and ERCP) in October 2012 due to anatomical complications related to his physical deformities. After these procedure…
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…
77y · Male·sepsis due to retroperitoneal collection after biliary stent insertion on a back…
A 77-year-old Aboriginal man died from sepsis following a percutaneous transhepatic cholangiography (PTC) procedure that perforated his duodenum. Critical failures included: delayed diagnosis and treatment of peritonitis…
76y · Male·end-stage renal failure
A 76-year-old man died of end-stage renal failure while imprisoned. He had pre-existing hypertension, diabetes, and stage 3 chronic kidney disease. During his final year in custody, he experienced acute kidney injury sup…
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…
75y · Female·septic complications following surgical resection of duodenal ampullary adenoma
A 75-year-old woman died of sepsis from bile leaking into her abdomen after elective surgery to remove a pre-malignant tumour adjacent to the bile duct. The coroner found multiple preventable failures: inadequate pre-ope…
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…
74y · Male·Aspiration of gastric contents due to paralytic ileus following Whipple surgery …
William Searle, a 74-year-old prisoner, died from aspiration of gastric contents following a Whipple procedure for recurrent ampullary adenoma. The clinical lessons involve recognition of gastroparesis risk in high-risk …
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…
53y · Male·Metastatic pancreatic carcinoma
Michael Sanderson, a 53-year-old Gamilaroi man, died from metastatic pancreatic cancer while in custody. Critical clinical lessons emerge: (1) failure to review pathology results within required 14-day timeframe delayed …
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