64y · Female·Cholecystitis with significant contributing condition of secondary progressive m…
…rticipant with secondary progressive multiple sclerosis residing in supported accommodation, died from cholecystitis following admission to hospital for recurrent gallbladder infections. She was deemed unsuitable for su…
85y · Male·Liver ischaemia and portal vein thrombosis complicating emergency cholecystectom…
…s including diabetes, pancreatitis, and gallstones, died following emergency cholecystectomy for acute cholecystitis with Mirizzi's syndrome. Intraoperative complications included major bile duct injury, right hepatic a…
86y · Male·Complications post laparoscopic cholecystectomy
86-year-old man with acute gangrenous perforated cholecystitis underwent laparoscopic cholecystectomy on 2 October 2015, forty-two hours after admission. Severe blee…
39y · Male·dilated cardiomyopathy
… He had a long-standing cardiac history including prior myocardial infarction, presenting acutely with cholecystitis, acute kidney injury, and multi-organ failure. The coroner found he received appropriate standard heal…
33y · Male·Multiple injuries sustained in a single vehicle crash, complicated by acalculous…
…as appropriate with initial improvement, but the deceased developed complications including acalculous cholecystitis with large abdominal abscesses and necrotizing fasciitis requiring surgery. A massive intracerebral bl…
94y · Male·Multi-system organ failure, peritonitis, acute gangrenous cholecystitis with cho…
…ase, diabetes, dementia), died of multi-system organ failure secondary to sepsis from acute gangrenous cholecystitis. An advanced care plan documented his wish for comfort-focused care only. Management by his GP include…
56y · Female·Aspiration Pneumonia in the setting of Cerebral Palsy and Epilepsy
…sy and epilepsy living in high-level residential care, presented with sepsis complicated by pneumonia, cholecystitis, and aspiration risk. Despite aggressive treatment including antibiotics, blood transfusion, and MET t…
76y · Female·multi-organ failure and sepsis due to complications of cholecystectomy
…, and right portal vein instead of the cystic structures. The underlying pathology—xanthogranulomatous cholecystitis—could not be detected preoperatively. The coroner found the death preventable: the surgeon should have…
52y · Female·Aspiration pneumonia in a female who had undergone a laparoscopic cholecystectom…
Angela Murray, a 52-year-old woman with intellectual disability, cerebral palsy, and epilepsy, died from aspiration pneumonia following laparoscopic cholecystectomy for cholangitis and cholelithiasis complicated by pancr…
53y · Male·Coronary atherosclerosis; chronic obstructive airways disease; chronic cholecyst…
Gregory Bert Smallwood, a 53-year-old prisoner with morbid obesity, hypertension, diabetes, and COPD, died from acute myocardial infarction due to severe coronary atherosclerosis. He called for help at 3:06am reporting i…
55y · Female·acute myocardial infarction due to right coronary artery thrombosis
…and vomiting was discharged without an ECG or troponin measurement. She had an abdominal CT suggesting cholecystitis, but the coroner's medical advisor noted that her symptoms strongly indicated possible acute coronary …
65y · Male·ischaemic and hypertensive heart disease with contributing acute cholecystitis (…
A 65-year-old man with hypertension presented with acute cholecystitis, underwent laparoscopic cholecystectomy, and initially recovered well. On post-operative day 7, he exp…
66y · Male·hepatic failure, intrahepatic sepsis and intrahepatic haematoma secondary to com…
William Ernest Pears died from hepatic failure, intrahepatic sepsis and haematoma following a laparoscopic cholecystectomy in 2012. During surgery for gallstone disease, the right hepatic duct was damaged and repaired, b…
68y · Male·surgical complications following laparoscopic cholecystectomy for cholecystitis,…
… multiple comorbidities, died from surgical complications after laparoscopic cholecystectomy for acute cholecystitis. Postoperatively, he developed profound hypotension. The treating team disagreed on whether the cause …
71y · Male·Complications following a right hepatic artery injury following an open cholecys…
…surgery died from complications of a right hepatic artery injury during open cholecystectomy for acute cholecystitis. The operative decision was reasonable and the intraoperative injury was appropriately managed. Howeve…
49y · Male·Metastatic cholangiocarcinoma
Jamie Walker, a 49-year-old man with pre-existing epilepsy, cirrhosis, and hepatitis C, died in custody from metastatic cholangiocarcinoma. He presented with abdominal pain and leg swelling; initial ED assessment on 19 O…
71y · Male·metastatic papillary renal cell carcinoma
Robert Bell-Williams, aged 71, died from metastatic papillary renal cell carcinoma while in lawful custody at Long Bay Hospital on 1 February 2024. Imprisoned since 2012, he was diagnosed with renal cell carcinoma in 202…
45y · Male·Sudden death of unascertained cause, occurring eight days after laparoscopic cho…
A 45-year-old man died unexpectedly 8 days after an uncomplicated laparoscopic cholecystectomy. Post-mortem examination found approximately 1 litre of blood in the peritoneal cavity. Pathologists could not determine when…
63y · Female·bile peritonitis as a complication from a laparoscopic cholecystectomy
A 63-year-old woman died from bile peritonitis following laparoscopic cholecystectomy. The surgeon's intraoperative management was appropriate with no identified injuries. However, critical clinical deterioration on post…
88y · Female·Head injury in a fall due to atrial fibrillation on anti-coagulants
An 88-year-old woman with atrial fibrillation on anticoagulation died from a subdural haemorrhage sustained in a fall at a rehabilitation hospital. She was assisted to the toilet by a single nursing student despite a doc…
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