45y · Female·Multi-organ failure due to septicaemia and peritonitis due to faecal leakage fro…
A 45-year-old woman died from multi-organ failure following failure of a loop colostomy created for management of an anastomotic leak after bowel cancer surgery. The initial anastomotic leak (…
59y · Female·Complications of a pseudo-obstruction on a background of previous anterior resec…
…ty. Admitted July 2024 with abdominal distension, she underwent flexible sigmoidoscopy, colonoscopy with colostomy formation, and experienced aspiration pneumonia. Despite maximal medical management, she developed recur…
33y · Male·Multi-organ failure due to sepsis on a background of severe ischaemic cardiomyop…
…opathy. He had a complex medical history including viral myocarditis, previous intestinal resection with colostomy, and recurrent heart failure admissions. His condition was significantly compromised by poor medication …
42y · Male·Gunshot wound to the head (self-inflicted)
…e. The death followed the recent ending of their relationship, which O'Rourke attributed to his upcoming colostomy surgery but was also driven by jealousy and perceived slights. O'Rourke had a significant criminal histo…
38y · Female·end stage renal failure (Stage 5 chronic kidney disease)
Ms Harwood, a 38-year-old transgender woman with end-stage renal disease, died of natural causes following refusal of dialysis. Her mother claimed the death was suicide prompted by fear of returning to prison following a…
65y · Male·peritonitis and necrosis of the bowel following a ruptured appendix
A 65-year-old prisoner with severe triple-vessel coronary artery disease died from peritonitis and bowel necrosis following an appendectomy. Initial surgery for perforated appendicitis was technically difficult but compe…
0y · Male·Complications of VATER syndrome and sacrococcygeal teratoma
Baby E was a 7-month-old neonate with VATER syndrome and sacrococcygeal teratoma who died from complications of these conditions. He was born prematurely at 30 weeks, requiring intubation and ventilation, and remained in…
47y · Male·pneumonia
Wayne Eadie, a 47-year-old man with intellectual disability living in residential care, died from community-acquired pneumonia complicated by acute-on-chronic renal failure. He presented unwell on 3 February 2012 and was…
51y · Female·peritoneal sepsis with multiple organ failure due to perforation of bowel by for…
A 51-year-old woman with intellectual disability and schizoaffective disorder died from peritoneal sepsis and multiple organ failure caused by bowel perforation from a wooden stick. The stick entered her body via her vag…
57y · Male·aspiration pneumonia secondary to small bowel obstruction
A 57-year-old man with chronic schizophrenia, intellectual disability, and history of bowel obstruction presented with faecal vomiting and signs of shock. He was appropriately transferred to hospital where small bowel ob…
49y · Female·Intra-abdominal haemorrhage, septic and haemorrhagic shock as a result of a lapa…
Deborah Burgen died from intra-abdominal haemorrhage complicated by septic shock following delayed emergency surgery for bowel obstruction. She attended the emergency department six times over eleven days with identical …
31y · Male·sepsis due to urosepsis and pneumonia on a background of C3 incomplete tetrapleg…
Michael Quinn, a 31-year-old quadriplegic inmate, died from sepsis secondary to urosepsis and pneumonia. He had C3 incomplete tetraplegia from a self-inflicted stab wound in 2013 and was serving a 20-year sentence. An in…
48y · Male·Hypoxic brain injury following cardiac arrest in a patient with sigmoid colon vo…
Daniel Allan Sullivan, a 48-year-old man with chronic paranoid schizophrenia who had been an involuntary patient at Graylands Hospital for 23 years, presented to Sir Charles Gairdner Hospital on 13 June 2004 with abdomin…
47y · Male·acute renal failure caused by bilateral ureteral obstruction due to metastatic c…
Sean Waygood, an Extreme High Security prisoner, died from acute renal failure caused by metastatic colorectal cancer. He presented with abdominal pain, constipation, and blood per rectum in March 2011 but received subop…
86y · Male·Septic shock secondary to urosepsis
Robert Avery, 86, was admitted to Valley Private Hospital for colonoscopy to investigate constipation. After the procedure was cancelled due to respiratory concerns, he was managed with fluid restriction, bowel preparati…
73y · Male·Disseminated malignancy (advanced lung carcinoma and mouth carcinoma) in a man w…
Robert Craig, aged 73, died from disseminated malignancy (advanced lung and mouth carcinoma) while in prison custody. He received suboptimal cancer treatment at Fiona Stanley Hospital due to communication failures betwee…
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 surgical error by exteriorising the…
64y · Male·necrotising fasciitis precipitated by a fishbone perforating his rectum, leading…
James Tranby, a 64-year-old Indigenous diabetic prisoner, presented with a fish bone lodged in his rectum on 3 December 2008. Following removal on 5 December, he developed progressive sepsis leading to necrotising fascii…
59y · Female·complications of intra-abdominal sepsis, including multi-organ failure and bowel…
59-year-old woman died from intra-abdominal sepsis, multi-organ failure and bowel perforation following median hepatectomy for cholangiocarcinoma. Key clinical issues included: surgical delays of 20 days between stent in…
62y · Female·Haemorrhage caused by abdominoperineal excision of the rectum
A 62-year-old woman died of uncontrollable haemorrhage following an abdominoperineal excision of the rectum (APER) at a remote hospital. The coroner found the operation itself was inappropriate: performed for undiagnosed…
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