65y · Male·metastatic rectal cancer with extensive lung metastases
…leeding symptoms since 2011 and returned a positive faecal occult blood test in March 2015 recommending colonoscopy. However, he subsequently declined multiple colonoscopy offers in 2018 and 2020 despite medical recomme…
47y · Male·cardiomyopathy in a 47 year old man with Down syndrome
…a 47-year-old man with Down syndrome and known cardiomyopathy with pacemaker, was admitted for elective colonoscopy. The anaesthetist reviewed him preoperatively and the procedure was completed quickly without apparent …
39y · Female·aspiration pneumonia in the setting of general anaesthesia and colonoscopy for i…
…r-old woman with cerebral palsy, dysphagia, and sleep apnoea died from aspiration pneumonia following a colonoscopy performed under sedation for investigation of rectal bleeding. She had known increased aspiration risk,…
54y · Female·Aspiration pneumonia
…cialist disability accommodation, died from aspiration pneumonia following an aspiration event during a colonoscopy performed at Dandenong Hospital on 19 July 2023. She was subsequently admitted to ICU where her conditi…
70y · Male·haemoperitoneum and ruptured spleen following colonoscopy
Alan Stewart, aged 70, died from a ruptured spleen about 24 hours after an elective colonoscopy at Royal Melbourne Hospital. The splenic injury resulted from mechanical trauma during the procedure—an…
70y · Male·haemoperitoneum secondary to ruptured spleen following colonoscopy
Alan Edward Stewart, aged 70, died from haemoperitoneum due to splenic rupture following routine colonoscopy at Royal Melbourne Hospital on 15 August 2018. The splenic injury was caused by mechanical trauma from …
69y · Female·Complications of a probable bowel malignancy
…bable bowel malignancy. In October 2014, regional lymphadenopathy and bowel thickening were identified; colonoscopy was not pursued due to concerns about distress and medication destabilisation. In March 2015, abdominal…
46y · Male·Complications of stage 4 colorectal cancer in a man with multiple medical comorb…
…nd chronic constipation, died from complications of stage 4 colorectal cancer. Cancer was discovered on colonoscopy in June 2017 during investigation of chronic constipation. He was deemed unsuitable for surgery or chem…
86y · Male·Aspiration Pneumonia secondary to Recurrent Colorectal Carcinoma
An 86-year-old man died from aspiration pneumonia following bowel preparation for elective colonoscopy. He was admitted to an outlying ward rather than the gastroenterology unit, where nursing staff documen…
37y · Male·hypoxic brain injury secondary to cardiac arrest as a result of bowel volvulus
…ardiac arrest before emergency services arrived. Rapid decompression of his grossly dilated abdomen via colonoscopy at hospital temporarily restored ventilation, but he had already suffered severe neurological injury fr…
48y · Male·Multi-organ failure from acute gastrointestinal haemorrhage associated with oeso…
…ognition of bleeding risk and expedited gastrointestinal evaluation (particularly given his refusals of colonoscopy) may have enabled preventive intervention such as variceal banding or beta-blocker prophylaxis before c…
37y · Female·Unascertained; possibly sudden cardiac arrhythmia
…, died unexpectedly at home on 8 January 2012 after taking prescribed bowel preparation (Picolax) for a colonoscopy. She ingested the preparation according to instructions but appears to have over-consumed water while t…
78y · Male·Complications of bowel surgery; specifically post-operative chest infection and …
Barry Howroyd, a 78-year-old man, underwent routine colonoscopy on 7 August 2008 which complicated a known bowel carcinoma diagnosis. The procedure caused bowel perfor…
55y · Male·probable sepsis in the setting of immunosuppression, a skin wound and chronic di…
…ng renal function (creatinine rising from 180 to 381 micromoles/L). Critical failures included: delayed colonoscopy (referred May 2016, not performed by death), infrequent specialist review (one visit in 9 months versus…
81y · Male·Intracerebral haemorrhage in the setting of heparinisation for subclavian artery…
81-year-old Alan Webster with atrial fibrillation on long-term Warfarin underwent colonoscopy in August 2011. His anticoagulation was interrupted and bridging Clexane prescribed. Post-operatively, …
59y · Female·Complications of a pseudo-obstruction on a background of previous anterior resec…
… bowel dysmotility. Admitted July 2024 with abdominal distension, she underwent flexible sigmoidoscopy, colonoscopy with colostomy formation, and experienced aspiration pneumonia. Despite maximal medical management, she…
76y · Male·metastatic prostate cancer with terminal palliative care
…s, specialist consultations, and high-quality palliative care. One minor issue was identified: a repeat colonoscopy recommended in 2020 was not scheduled until 2022 (and subsequently cancelled due to COVID-19), attribut…
52y · Female·Unascertained (natural causes)
…elangiectasia, and low iron stores, but no definitive diagnosis. Despite comprehensive workup including colonoscopy, gastroscopy, and bone marrow biopsy, the underlying cause remained unclear. She was appropriately tran…
72y · Female·Large rectal prolapse and ischaemic bowel
…olapse symptoms at the aged care facility and prompt emergency response were appropriate. The cancelled colonoscopy scheduled for 3 December may have represented a missed opportunity for earlier intervention, though the…
63y · Male·metastatic rectal carcinoma
…ion). Annual health reviews, faecal occult blood testing, and weight monitoring were not performed. Had colonoscopy been offered and accepted in 2015, tumour may have been curable; if diagnosed in 2016-2017, treatment m…
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